Senior. Manager,Claim Quality Support - 155411
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.
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.
The Sr. Manager, Claims Quality Support oversees the timely resolution of all post claims adjudication tasks including, but not limited to, priority reconsideration requests, payment disputes, and claim appeals. This position leads all in-house Coordination of Benefits and Recoupment efforts and works in tangent with Configuration Support on recoupment opportunities identified. This position works to address iterations of training needs as part of continuous quality improvement support for claims staff. This position ensures the success of post payment tasks by adopting a culture of excellence. This leader identifies service level trends and conveys findings to applicable unit leaders within Community Health Choice.
- Bachelor's degree or four years claims experience in lieu of degree required.
- Seven years of claims with a health plan or Third Party Administrator.
- Experience in a production environment utilizing technology platforms and support related to system upgrades and testing relative to claims applications and tools.
- Five years managing claims appeals, disputes, adjustments or healthcare compliance for a health plan or third party administrator with multidisciplinary teams.
- Microsoft Office (Word, Excel, Outlook); Claims Applications; QNXT or EPIC Systems a plus.
- Experienced in policy interpretation related to appropriateness and accuracy of payment disputes, appeals, reconsiderations and industry practices.
- Multi-tasker with excellent analytical and leadership skills with the demonstrated ability to achieve key departmental objectives.
- Broad range of experience including Commercial, Medicare and Medicaid lines of business.
- Familiar with various payment methodologies and contract language in an effort to assess provider billing appropriateness and claim billing practices looking for potential fraud, waste, and abuse.
Benefits and EEOC
Community employees’ benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.
Community is an Equal Opportunity Employer.