Provider Research Coordinator
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: Provider Research Coordinator is a position within the Community Health Choice Provider Call Center. The Provider Research Coordinator is primarily responsible for, but not limited to responding to incoming provider hotline inquiries as they relate to benefit and eligibility verification, claim status (with the ability to identify if a claim requires reconsideration), authorization status, and complaints, accurate documentation recording of all provider calls; effective follow-up of provider calls, as required; and proper electronic routing with effective documentation skills.
JOB SPECIFICATIONS AND CORE COMPETENCIES
- Interpret and explain health plan benefits, policies, procedures and functions to providers, medical groups, or representatives of provider offices.
- Review, analyze and process routine and more complex provider disputes, requiring a more in-depth understanding of appropriate payment or denial practices, benefits, policies and procedures, and contract interpretation.
- Identify claims processing issues that result in Provider Relations and work collaboratively with the Claims Processing Supervisors and the Claims Production Manager to correct.
- Ability to respond effectively and timely to inbound calls from provider offices regarding benefits and eligibility, claims processing status, and authorization status.
- Marginal Functions
- Maintains a professional behavior and exhibit excellent interpersonal skills
- Works collaboratively with coworkers to deliver member/provider services that meet or exceed member/provider expectations
Reports to Position Title: Director Customer Experience
Employees Supervised Titles: Supervisors
- Education/Specialized Training/Licensure: High school or equivalent; Associates preferred
- Associates and two years; or Four years in lieu of degree with relevant work experience.
- Experience to include Health Care/Plan with claims knowledge. Cross-functionality in Claims, Authorizations,
- Benefits and Eligibility.
- Microsoft Office (Word, Excel, Outlook)
Organizational Core Competencies: All employees are responsible for understanding and demonstrating Community Health Choice core competencies:
- Customer Focus , Sustainability
- Reliability and Dependability ,
- Employee Empowerment
- Honesty & Integrity Sustainability
- Achievement Orientation Sustainability
- Change Management Affordability
- Team Work Employee Empowerment
- Analytical Thinking
- Attention to Detail
- Diagnostic Information Gathering
- Writing /Composing, Medical Terminology , Above average verbal
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
Job Status: Full Time
Job Reference #: 166963