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 Secondary Review and Notification RN is responsible for subsequent review 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.  The Secondary Review and Notification RN utilizes critical thinking and experience to make certain that citations of regulatory requirements occur and that an accurate assessment of unmet needs has been documented.  In addition, the Secondary Review and Notification RN is also responsible for completing the regulatory requirements for notification of determinations to members and/or providers. As a secondary reviewer you will be responsible for providing feedback, confirming the original decision, or raising concerns if needed. This position will work closely with the Utilization Management (UM) team, Service Coordination (SC) team and Medical Directors when required.


JOB SPECIFICATIONS 

Responsible for secondary review of LTSS service approvals, denials, increases, reductions and terminations, will provide feedback to confirm previous decisions or raise awareness when needed on decisions made by the SC and UM team.

Complete and 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.
Provide secondary support in the development and generation of adverse determination letters. Review of adverse determination letters for accuracy and appropriateness of Medical Director documentation to ensure compliance to all regulatory requirements prior to mailings.

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.


QUALIFICATIONS: 

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

BSN preferred.

Work Experience (Years and Area): 
3 years clinical experience in a managed care organization.  
3 years experience working in Utilization Management environment. 
3 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.

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

Application Instructions

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