Claims Benefits Specialist - The Health Plan

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.  

Summary:

We are on the hunt for a Claims/Benefits Specialist—someone who can thrive in a fast-paced managed care environment. In this position, you’ll investigate and accurately process claim appeals within the regulatory requirements mandated by the State of Texas. We need someone who can provide effective, timely investigations and follows up on all internal customer requests.

 

Think you’ve got what it takes?

Responsibilities :

Job Duties:

• Ensures appeals are processed according to claims processing guidelines
• Review and process pended claims within 5 days of initial review
• Provides an exceptional level of customer satisfaction
• Provides effective, timely investigations and follow up on all internal customer requests and special projects
• Ensures claim checks are processed in a timely and efficient manner
• Participates in the development/achievement of action plans and goals
• Identify trends related to appeals processing
• Process refunds/retractions identified by TCHP contracted vendors within 30 days of notification
• Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt

 

Qualifications:

Requirements:

• High School diploma or GED
• Three (3) years of claims examination experience
• In lieu of 3 years experience, a Bachelor’s Degree or higher will be accepted
• Knowledge of ICD9 and CPT coding
• Knowledge of claims examination functions
• Ability to perform clerical duties and operate PC and general office equipment

Apply Now 