Teams at Cook Children's Health Care System

Audits behavioral and medical claims for Texas Medicaid and CHIP programs, including post-payment reviews, claim sampling, high-dollar pre-audits, coding and system configuration validation, and payment integrity checks. Prepares structured audit reports, communicates findings to reimbursement and claims teams, and ensures compliance with regulatory standards, contracts, HIPAA, security rules, and required timelines.

Manages patient relations and serves as a neutral liaison between patients, families, and caregivers. Oversees complaints, grievances, patient rights, regulatory compliance, service recovery, and departmental staff. Leads process improvement, analyzes grievance trends, coordinates family meetings, maintains regulatory policies, and collaborates with hospital leadership, legal teams, and clinical stakeholders to resolve issues within required timeframes.

Analyzes healthcare claims data to identify recovery and cost-containment opportunities, audits provider contracts and delegated entities, and ensures claims payment configurations comply with Medicaid, CMS, Texas regulatory, and contractual requirements. Interprets business requirements, supports benefit and fee-schedule configuration, and collaborates with Claims, Provider Contracting, Compliance, Finance, and Information Systems teams.