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 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.     

MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure:

  • Bachelor's Degree or 4 years claims experience in lieu of degree required.

Work Experience (Years and Area):

  • Seven (7) 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.

Management Experience (Years and Area):

  • Five (5) years managing claims appeals, disputes, adjustments or healthcare compliance for a health plan or third party administrator with multidisciplinary teams.

Software Operated:

  • Microsoft Office (Word, Excel, Outlook);
  • Claims Applications;
  • QNXT or EPIC Systems a plus.

Other Requirements:

  • 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.


SPECIAL REQUIREMENTS: 

Communication Skills:

  • Above Average Verbal (Heavy Public Contact)
  • Exceptional Verbal (e.g., Public Speaking)
  • Writing /Composing: Correspondence / Reports


Other Skills:

  • Analytical, Medical Terminology, Research, Statistical, MS Excel


 Advanced Education:

  • Bachelor's Degree Major: Preferred


RESPONSIBLE TO: Director

EMPLOYEE SUPERVISED: Professional/Staff

Application Instructions

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