Job Description

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Skills / Requirements

The Claims Audit Manager results oriented leader responsible for managing the timely resolution of initial (front-end) claims and specified claims adjustments for marketplace. This position leads efforts to identify opportunities for continuous process improvement to improve quality outcomes by analyzing trends and identifying payment deficiencies.  The Claims Manager is responsible for collaborating with Claims Supervisors to provide strategic and operational guidance designed to improve the overall claims adjudication experience.   Manage key performance indicators to achieve established performance measures. Oversee claims inventory and workload; improve quality outcomes. Identify training opportunities. Manage all reporting requirements. Resolve escalated and complex issues.  Demonstrate experience in leading, mentoring and inspiring team members to achieve superior results.  Other duties as assigned.

Accountable for managerial oversight of Claims Auditing Programs. Additionally, this position is responsible for post payment claims audit collaboration with external  claim appeal file analysis. This position is responsible for monitoring and identifying inappropriate inconsistent/inaccurate provider billing patterns. This position will be constantly auditing various provider claims to detect opportunities for improvement in claims payment, contracting and utilization management. Identify risks related to claims processing and work with Claims Operations to develop processing and payment workflows specific to Medicare/Medicare Advantage, Marketplace and Medicaid. 

QUALIFICATIONS:

  • HS or equivalent required.
  • Bachelor's degree preferred.
  • Nine years' experience to include7 years minimum claims adjudication experience required (health plan or managed care organization)
  • OR seven years minimum claims adjudication experience (health plan or managed care organization) with degree required.
  • Extensive knowledge of Medicare/Medicare Advantage processes and regulatory requirements preferred.
  • Knowledge of Medicaid and Marketplace claims processing requirements preferred.
  • Two years supervisory experience with a health plan and/or Third-Party Administrator (TPA) required.
  • Five years leadership experience in auditing or healthcare claim appeals, preferably with Medicare /Medicare Advantage preferred.

OTHER SKILLS:

  • Software Proficiencies: Microsoft Office (Word, Excel, Outlook) required.
  • Strong critical thinking and analytical skills required.

Application Instructions

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