STAR + PLUS - Provider Contract 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
Responsible for providing support for the provider contracting process. Organizes contract inventories and verifies that all required documents are received from providers and complete. Ensures all contract requests are submitted in internal systems, and to the appropriate Provider Contract Specialist or Senior Provider Contract Specialist within defined internal timeframe or regulatory requirement. Route signed provider contracts through defined approval process. Arrange and maintain information for network recruitment, inclusive of network adequacy requirements designated by regulatory agencies, which may include prospecting and outreach to prospective network providers. Following monthly MCMC meeting, forward Welcome Packet and executed agreement to providers within defined timeframe and submit to Payment Solutions team for loading. Ensure all provider files in pending status are followed up in a timely manner indicated in the departmental policy and procedure. Prepare provider termination forms, program adds, and demographic changes and submit to Payment Solutions within defined regulatory timeframes. Confirm quality and completeness of information in files (for example, W-9, contracts, correct effective dates etc.) and loaded in appropriate internal systems.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Manage provider contracting workflow from initial intake to contract loading, including, but not limited to, collection of missing information, verification of complete application, sending welcome packets to providers.
Prepare provider termination forms, program adds, and demographic changes and submit to Payment Solutions within defined regulatory timeframes.
Serve as a liaison between Community and its providers, as appropriate, including acknowledging receipt of application packet, collecting missing information from application packet, status requests, and other provider inquiries.
Arrange and maintain information for network recruitment, inclusive of network adequacy requirements designated by regulatory agencies, which may include prospecting and outreach to prospective network providers.
Actively contribute to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans.
Other duties as assigned.
Education/Specialized Training/Licensure: High School Diploma or Equivalent required
Work Experience (Years and Area): 1 year relevant work experience required
Management Experience (Years and Area): N/A
Software Proficiencies: Microsoft Office (Word, Excel, Outlook) required
Other: Must Have Vehicle and Valid State of Texas Driver's License required
Experience with Star Plus, LTSS, HCBPs, and Medicare products a plus preferred.
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Job Status: Full Time
Job Reference #: 166904