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

Under the supervision of STAR PLUS Supervisor of State Fair Hearing Appeals and Grievance will review SFH/EMR request and collaborate with STAR PLUS Service Coordinator to ensure all The STAR + PLUS STATE FAIR HEARING/EMR COORDINATOR will attend any mandated HHSC trainings.

JOB SPECIFICATIONS 

Essential Functions

  • Prepare and submitting case file (EMR and SFH packets) for External Reviews and/or State Fair Hearing that pertain to LTSS services.
  • Oversee and survey all appeals from Out- of -Network providers related to LTSS Services for as set forth by the CHC Model of Care for Star Plus members.
  • Work autonomously and with agency to prepare well pertinent, individualized responses to all provider inquiries regarding LTSS services in any capacity.
  • Ensure timely analysis, indagating, and final resolve of LTSS appeals EMR and /or State Fair Hearings. Ensures that all appeals and EMR/SFH are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy.
  • Consults with Vice President of Medical Affairs, Senior Manager of Appeals and Grievances, Supervisor of SFH/EMR, Star Plus Associate Medical Directors, and Star Plus Care Coordinators and Appeals and Grievances staff on problem cases and interfaces with clinical supervisors, account managers, and other personnel in resolving health plan requests or provider inquiries as pertaining to Star Members and LTSS services.
  • Enter into ledger and monitor appeals, and other types of inquiries as needed pertaining to LTSS services.
  • Review and determine outcome of appeal, EMR/SFH, either independently or in conjunction with clinical appeal staff regarding LTSS services.
  • Consults with subject matter experts such as CHC State Compliance and resources available within organization to assist in appeal resolution as related to LTSS services.
  • Make critical decisions regarding research and investigation to appropriately resolve all inquiries for Star Plus members and their LTSS services.
  • Serve as a point of contact to Appeals Coordinator and receives guidance and expertise to ensure timely resolution of cases.
  • Other duties and responsibilities as assigned and as CHC Appeals Department deems necessary.


QUALIFICATIONS:

  • Education/Specialized Training/Licensure: High School Diploma or Equivalent required.
  • Work Experience (Years and Area): 3 years of experience and knowledge regarding Star+ Plus benefits for STARPLUS, the STAR+PLUS Handbook, the UMCC, and UMCM.
  • 5 or more of years experience in a MCO for STAR PLUS
  • Software Proficiencies: Microsoft Word, OICS

Application Instructions

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