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:  Senior Manager of Complaints and Appeals ensures the proper management of all provider and member complaints as they relate to Adverse Determinations.  The Senior Manager ensures that all regulatory deadlines are met.  The Senior Manager of Complaints and Appeals will also apprise the Director of Quality & Outcomes in Medical Affairs of trends in adverse determinations that are either provider specific or specific to severity or intensity of service delivery.

The Senior Manager also acts as the lead Manager/trainer for the appeals team in the Medical Affairs Department. In this capacity, s/he will be responsible for orientation and training of new hires in the department as well as training for new products and product updates.

The Senior Manager is responsible for Quality Assurance of medical decision making for the appeals that are processed in the Medical Affairs Department. Together with the Department¿s management team the Senior Manager will develop and implement regular Inter-rater Reliability Reviews for clinical appeals staff to ensure consistent application of evidence-based guidelines, Policies, or other authorization criteria as adopted by the health plan. Similarly, the Manager will review appeal results of overturned adverse determinations to identify areas requiring individual or departmental education.

1. Education/Specialized Training/Licensure: Registered Nurse, current Texas License
2. Work Experience (Years and Area): At least 1 year as RN in acute care setting. Additional 1 year experience in Quality Improvement and in managed care setting preferred.
3. Management Experience (Years and Area): At least 1 year
4. Equipment Operated: Computer with knowledge of Word, Excel, Access and Outlook

SPECIAL REQUIREMENTS:  Strong written and verbal communication skills (heavy public speaking), writing/composing correspondence and reports.

OTHER SKILLS:  Analytical, medical terms, research, statistical, P.C., MS Word, MS Excel, MS Access, Typing: 35 wpm.


Application Instructions

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