Provider Reimbursement Specialist - The Health Plan

Position: Provider Reimbursement Specialist - The Health Plan

Job ID: 151301

Location: US-TX-Bellaire

Department: Contract Administration

Talent Area: Professional - Non-Clinical

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 for career opportunities. You can also learn more about our amazing culture at


We are searching for a Provider Reimbursement Specialist— someone who works well in a fast-paced setting. In this position, you will maintain and implement procedures supporting the rules and regulations set by all regulatory entities or as contractually outlined in provider agreements. You will oversee the timely processing of provider reimbursement information and accurately calculate reimbursement formulas based on negotiated contracts. Lastly, you will ensure that processing meets all regulatory and contractual requirements, including timeframes, documentation, and communication with providers. 


Think you’ve got what it takes?

Responsibilities :

Job Duties & Responsibilities


  • Monitor multiple primary sources and implement hospital and FQHC/RHC reimbursement changes on a monthly/annual basis
  • Develop, implement and audit all payment structures including but not limited to complex reimbursement set-up, quality incentives, gain sharing, risk-sharing or bundled pricing models
  • Assist with the tracking and measurement of contract and payment compliance
  • Act as subject matter expertise on state Medicaid reimbursement requirements and health plan system limitations
  • Engage in continuous study of the Medicaid reimbursement methodology, including best practices, to develop and maintain the competence, knowledge, and skills necessary for the satisfactory performance of all assigned responsibilities



Skills & Requirements


  • High school diploma or GED
  • A minimum of 7 years’ combined managed care contracting, provider reimbursement and analysis, strategic planning or project management experience
  • A bachelor’s degree may substitute for 4 years of the required experience

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