Complaint Resolution Spec

Job Description

We're searching for a Complaint Resolution Specialist, someone who works well in a fast-paced setting. In this position, you'll investigate and resolve member and provider complaints about claim issues, coordinate member complaint investigations and resolutions about non-claim issues and coordinate adverse determination appeals.

Think you’ve got what it takes?

Job Duties & Responsibilities

• Serve as recipient of member and provider complaints related to claim issues, as well as member complaints that are non-claim issues
• Forward cases to appropriate department/staff according to subject matter when appropriate and generate acknowledgment letters within 5 business days of receiving complaint
• Serve as liaison with other departments to facilitate member and providers claim complaint closures
• Prepare and present claim complaint cases to the Advisory Committee, when appropriate
• Serve as recipient of complaints that are received from state agencies HHSC and TDI
• Serve as a coordinator for the member, Hearing Officer assigned by HHSC and the manager of Utilization Management
• Establish and maintain a Fair Hearing file
• Enter appropriate information into the TMHP database, which alerts the Hearing Officer that a Fair Hearing has been requested and into MACESS
• Coordinate and send member information provided by Utilization Management
• Work on projects as assigned to prepare for external and internal reviews
  
  
  

Skills & Requirements

• High School Diploma or GED required
• 2 years of managed care experience in the HMO, IPA or Medical Group setting required
• Knowledge of managed care, preferably member services, quality and claims processing
• Excellent verbal and written skills as well as strong computer skills
  
  
  

About Us

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.

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.