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