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:

Accountable for oversight of Claims Department Training and Auditing Programs. Additionally, this position is responsible for pre-litigation and claim appeal file analysis. This position is responsible for monitoring and identifying inappropriate provider billing patterns. his position will be constantly auditing various provider claims to detect opportunities for improvement in claim payment, contracting and utilization management. Identify risks related to claims processing and work with Claims Operations to develop processing and payment workflows specific to Medicare/Medicare Advantage, Marketplace and Medicaid.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Essential Functions
15 % Apply policy interpretation related to appropriateness and accuracy of payment practices for Medicare Advantage, Medicaid and Marketplace
15 % Multi-tasker with extensive experience and judgment necessary to achieve key departmental audit initiatives
20 % Utilize experience with various payment methodologies and contract language to assess provider billing appropriateness and claim billing practices looking for potential fraud, waste, and abuse to complete audit requirements.
10 % Escalate quality issues to appropriate and submit timely notifications to Compliance Officers when necessary.
20 % Identify quality risks through auditing program and work with Operational leaders to implement appropriate strategies to mitigate risks identified.
10 % Compile weekly, Monthly, Quarterly, and Year to Date statistics related to Claims Audit

Marginal Functions
5 % Perform routine and ad-hoc analysis of processes related to deficiencies identified via auditing processes.
5 % Perform external delegation audit function (vision & dental providers) of audit program relative to claims payment

Reports to Position Title: Director Claims
Employees Supervised Titles: Claims Supervisor

MINIMUM QUALIFICATIONS:

• Education/Specialized Training/Licensure:
  • HS or equivalent
• Work Experience (Years and Area):
  • Bachelors and 7 years claims managerial experience;
  • or 11 years of health plan leadership experience with a health plan or Third-Party Administrator in lieu of degree.
  • Preferred: Extensive knowledge of Medicare/Medicare Advantage processes and regulatory requirements and / or Knowledge of Medicaid and Marketplace claims processing requirements.
• Management Experience (Years and Area):
  • 5 years Management experience with health plan and/or Third-Party Administrator (TPA)
  • Preferred: 5 years leadership experience in auditing or claim appeals, preferably with Medicare /Medicare Advantage
• Software Proficiencies:
  • Microsoft Office (Word, Excel, Outlook)
  • Claims Applications: QNXT or EPIC Systems a plus
• Other:
  • Strong critical thinking and analytical skills required.

INTERPERSONAL SKILLS:

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