Claims Auditor - Community Health Choice - Remote
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
JOB SUMMARY: To review claims for both new hires and experienced examiners and claim adjusters in a timely and consistent manner, and generate accuracy reports per examiner to be reviewed by Supervisor, and Senior Management. Responsibilities also include the review and auditing of the Provider Communication, Provider Fee Schedule and Provider Database team. Quality Analyst will be responsible for auditing, training, and some reporting functions.
1. Education/Specialized Training/Licensure:
- High school Graduate or GED equivalent
2. Work Experience (Years and Area):
- Minimum five years experience claims adjudication, a minimum two years auditing experience
3. Equipment Operated:
- PC, 10 key skills, medical coding, CPT and HCPC coding.
1. Communication Skills:
Exceptional Verbal (e.g., Public Speaking)
Writing /Composing (Correspondence / Reports)
2. Other Skills:
Analytical, Medical Terms, Research, P.C.
3. Other Requirements: Knowledge of ICD-9 coding, HCPCS, and CPT codes. Good Interpersonal skills.