Eligibility Specialist

At Texas Children’s Hospital, our mission starts with our people. Guided by our HEART values—Humility, Excellence, Accountability, Respect, and Trust—we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day.    As an Eligibility Specialist, you will ensure that member eligibility data is accurate and complete by auditing, validating, reconciling, and updating the data in the claims processing system. Provide a comprehensive and timely response to member eligibility inquiries from internal and external stakeholders.

Job Duties & Responsibilities
•    Validate and reconcile member eligibility data in the claims processing system after each daily and monthly file load to ensure it matches the data received from the State
•    Manually update member eligibility data in the claims processing system using multiple sources for reference, including applications, databases, and reports
•    Ensure member eligibility data is processed in accordance with Health Plan and department policies and procedures, as well as State guidelines and requirements
•    Review member eligibility data provided by the State in daily and monthly files (834, Capitation, and Capitation Adjustment)
•    Meet established performance/productivity and quality metrics for timely and accurate member eligibility
•    Collaborate with Health Plan business partners, as needed, to research and resolve member eligibility issues to ensure that members have access to care and claims are processed timely and accurately
•    Address member eligibility issues submitted via the Eligibility group email boxes and Macess service forms, as well as reports submitted via a secure FTP site
•    Appropriately escalate substantial member eligibility issues to management
•    Review and respond to member eligibility inquiries within established timeframes from both internal and external stakeholders; thereby, ensuring that the TCHP Business Operations Department meets its service level agreements (SLAs)
•    Review inquiries from the State with the appropriate Health Plan leadership and/or business partners, as needed, prior to responding
•    Complete inquiries submitted via the Eligibility group email boxes and Macess service forms
•    Ensure that responses to inquiries meet Health Plan and department policies and procedures, as well as State guidelines and requirements

Skills & Requirements
•    High School Diploma or GED Required
•    Bachelor's Degree Preferred
•    2 Years Previous Experience Working at or with an HMO Or MCO Organization Required