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

JOB SUMMARY 

The Manager, Secondary Review & Notification is responsible for managing the Secondary Review & Notification, RN team. Responsible for managing escalations of redeterminations related to LTSS service approvals, denials, increases, reductions and terminations, as well as service planning and documentation to ensure appropriate services are rendered. 

JOB SPECIFICATIONS 

Responsible for oversight of the secondary review process for LTSS services including approvals, denials, increases, reductions and terminations
Responsible for oversight of the notification process for acute and LTSS services 
Monitor letter generation and mailing accuracy of all adverse determination letters to ensure compliance while accurately entering the required information into the managed care platform, adhering to regulatory policies and procedures.
Actively contributes to achievement of departmental goals, as identified in  
Departments annual business plan, including specific departmental process  
improvement plans and other duties as assigned. 

Reports to Position Title: Sr. VP Health Services 
Employees Supervised Titles: Secondary Review and Notification, RN

QUALIFICATIONS: 

Education/Specialized Training/Licensure: Current, unrestricted RN license in the state of Texas required.

BSN preferred.

Work Experience (Years and Area): 
5 years clinical experience in a managed care organization.   
4 years experience working in Utilization Management environment.  
4 years experience working within applicable state, federal, and third-party regulatory agencies i.e., CMS, HHSC, TDI and Medicaid/Medicare population experience required.

LTSS Utilization Management environment preferred.

Management Experience (Years and Area): 3 years experience in management /leadership role 

Software Proficiencies: Microsoft Office (Word, Excel, and Outlook)

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

Apply Online