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

Childrens 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.

JOB SUMMARY :
The Medicare Claims Manager is responsible for claims appeals, claims adjustments, preparation and submission of regulatory deliverables, staff training, professional development of staff, product implementation, writing policies and procedures. This position also includes assisting with development of departmental reference guidelines and staff training program. This position requires strong communication skills, leadership skills and proven management ability.

The Medicare Claims Manager is responsible for management oversight of Medicare Claims (DSNP, Medicare Advantage and Part C provider Appeals) and to ensure compliance of regulatory requirements. Responsible for managing compliance requirements which includes timely and accurate resolutions of provider disputes and provider payment appeals. The Medicare Claims Manager is responsible for the daily oversight of provider disputes and provider appeals resolution, monitoring of inventory and accurate reporting. The Medicare Claims Manager will development and implement applicable policies and procedures, training programs and identify root causes and perform risk assessments of claims payment issues to effectively resolve provider payments and disputes.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Essential Functions:
20% Oversight of reconsideration and appeals claims.
15% Oversee all aspects of overpayment recovery opportunities.
10% Ensure timely responses (both internal/external) related to provider and member inquires.
5% Ensure effective hiring, training and coaching of staff
5% Complete performance evaluations for direct reports
10% Effective collaboration with other teams to ensure timely and accurate resolution of payment disputes, provider appeals and timely resolution of member requests for payments.
10% Coordination of staffing tasks develop workflows and strategies to achieve performance goals
10% Develop department metrics and performance standards; assists team in meeting or exceeding departmental performance standards

Marginal Functions:
5% Present, Monthly, Quarterly, and Year to Date statistics related to Payment Integrity.
5% Perform routine and ad-hoc analysis of processes related to COB and or Recovery opportunities.
5% Supervision of Vendor relationships relative to Payment Integrity


Reports to Position Title: Director Claims
Employees Supervised Titles: Claims Processor; Claims Adjustment Analyst


MINIMUM QUALIFICATIONS:

• Education/Specialized Training/Licensure:
  • HS or equivalent,
  • Bachelor's preferred
• Work Experience (Years and Area):
  • Bachelors with 5 years claims adjudication and/or grievance and appeal work experience in health plan / managed care environment;
  • or 9 years' experience in lieu of degree
• Management Experience (Years and Area):
  • 5 years Management experience with health plan and/or Third-Party Administrator (TPA)
• Software Proficiencies:
  • Microsoft Office (Word, Excel, Outlook)
• Other:
  • Strong critical thinking and analytical skills required.

INTERPERSONAL SKILLS:

Excellent interpersonal, written and verbal communication skills required. Ability to maintain strict confidentiality.