Provider Complaint Specialist - The Health Plan

 
Position: Provider Complaint Specialist - The Health Plan

Job ID: 150550

Location: US-TX-Bellaire

Department: Contract Administration

Talent Area: Administrative Support

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p Monday - Friday

About Texas Children's Hospital

The Texas Children’s Hospital system is the largest pediatric integrated care system and is an industry leader in pediatric population health.    Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children and pregnant women.  We are an Integrated Community System providing holistic care that empowers families to live healthier lives.  Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.  Currently, the Health Plan serves more than 450,000 members across three state territories (Harris, Jefferson, North East), who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. To join our community of 13,000 dedicated team members, visit www.texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at www.infinitepassion.org

Summary:

We are searching for a Provider Complaint Specialist — someone who works well in a fast-paced setting. In this position, you’ll be responsible for all provider complaints received either from regulatory entities or directly from providers. You will provide resolution in accordance with regulatory and NCQA guidelines, contractual obligations, and the health plan policy. You will provide effective verbal and written communication to internal and external parties of provider complaint analysis, outcomes, and resolutions.

 

Think you’ve got what it takes?



Responsibilities :

Job Duties & Responsibilities 

HOU123 

  • Serve as the primary lead for all provider complaints received from regulatory agencies, providers, or health plan departments
  • Research complaints using our internal systems/databases, quickly identify and assess provider issues, and resolve them within the allotted time frames
  • Serve as a liaison between internal departments as complaint research and analysis determine which staff is needed to resolve the complaint
  • Perform analyses on trends and findining and recommend mitigation strategies
  • Communicate investigation with other departments/state agencies when needed
  • Prepare correspondence, summaries, and documents for tracking/trending data
  • Establish an efficient system for collecting complaints
  • Partner with the training team as needed to ensure appropriate content is incorporated into staff and team training materials

 



Qualifications:

Skills & Requirements

 

  • High school diploma or equivalent required
  • 3 years’ experience with combined managed care customer service, provider appeals/grievances, strategic planning, or project management
  • Bachelor’s degree may substitute for experience


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