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.
JOB SUMMARY:
The Claims Manager role is responsible for the timely payment of initial claims submissions, claim adjustments, preparation and monitoring of regulatory deliverables, staff training, professional development, policies and procedures and development of workflows, accurate processing of claims, and identifying training needs. The Claims Manager will identify root causes of payment discrepancies; perform risk assessments and effectively resolve provider payment submissions. Identify training development needs for staff members and support coaching and champion employee engagement support.
POSITION AREAS INCLUDED: Marketplace / Medicaid / Claims Audit / Medicare
Manager, Claims (Marketplace)
Results oriented leader responsible for managing the timely resolution of initial (front-end) claims and specified claims adjustments for marketplace. This position leads efforts to identify opportunities for continuous process improvement to improve quality outcomes by analyzing trends and identifying payment deficiencies. The Claims Manager is responsible for collaborating with Claims Supervisors to provide strategic and operational guidance designed to improve the overall claims adjudication experience. Manage key performance indicators to achieve established performance measures. Oversee claims inventory and workload; improve quality outcomes. Identify training opportunities. Manage all reporting requirements. Resolve escalated and complex issues. Demonstrate experience in leading, mentoring and inspiring team members to achieve superior results. Other duties as assigned.
JOB SPECIFICATIONS AND CORE COMPETENCIES: Marketplace
Essential Functions
Apply policy interpretation related to appropriateness and accuracy of payment practices for Medicare Advantage, Medicaid and Marketplace and Star Plus
Multi-tasker with extensive experience and judgment necessary to achieve key departmental audit initiatives
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.
Escalate quality issues to appropriate and submit timely notifications to Compliance Officers when necessary. Create appropriate reporting of auditing statistics
Identify quality risks through auditing program and work with Operational leaders to implement appropriate strategies to mitigate risks identified.
Compile weekly, Monthly, Quarterly, and Year to Date statistics related to Claims Audit
Marginal Functions
Perform routine and ad-hoc analysis of processes related to deficiencies identified via auditing processes.
Perform external delegation audit function (vision & dental providers) of audit program relative to claims payment
Manager, Claims (Medicaid)
Results oriented leader responsible for managing the timely resolution of initial (front-end) claims and specified claims adjustments for marketplace. This position leads efforts to identify opportunities for continuous process improvement to improve quality outcomes by analyzing trends and identifying payment deficiencies. The Claims Manager is responsible for collaborating with Claims Supervisors to provide strategic and operational guidance designed to improve the overall claims adjudication experience. Manage key performance indicators to achieve established performance measures. Oversee claims inventory and workload; improve quality outcomes. Identify training opportunities. Manage all reporting requirements. Resolve escalated and complex issues. Demonstrate experience in leading, mentoring and inspiring team members to achieve superior results. Other duties as assigned.
JOB SPECIFICATIONS AND CORE COMPETENCIES: Medicaid
Essential Functions
Apply policy interpretation related to appropriateness and accuracy of payment practices for Medicare Advantage, Medicaid and Marketplace and Star Plus
Multi-tasker with extensive experience and judgment necessary to achieve key departmental audit initiatives
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.
Escalate quality issues to appropriate and submit timely notifications to Compliance Officers when necessary. Create appropriate reporting of auditing statistics
Identify quality risks through auditing program and work with Operational leaders to implement appropriate strategies to mitigate risks identified.
Compile weekly, Monthly, Quarterly, and Year to Date statistics related to Claims Audit
Marginal Functions
Perform routine and ad-hoc analysis of processes related to deficiencies identified via auditing processes.
Perform external delegation audit function (vision & dental providers) of audit program relative to claims payment
Manager, Claims (Claims Audit)
Accountable for managerial oversight of Claims Auditing Programs. Additionally, this position is responsible for post payment claims audit collaboration with external claim appeal file analysis. This position is responsible for monitoring and identifying inappropriate inconsistent/inaccurate provider billing patterns. This position will be constantly auditing various provider claims to detect opportunities for improvement in claims 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: Claims Audit
Essential Functions
Apply policy interpretation related to appropriateness and accuracy of payment practices for Medicare Advantage, Medicaid and Marketplace and Star Plus
Multi-tasker with extensive experience and judgment necessary to achieve key departmental audit initiatives
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.
Escalate quality issues to appropriate and submit timely notifications to Compliance Officers when necessary. Create appropriate reporting of auditing statistics
Identify quality risks through auditing program and work with Operational leaders to implement appropriate strategies to mitigate risks identified.
Compile weekly, Monthly, Quarterly, and Year to Date statistics related to Claims Audit
Marginal Functions
Perform routine and ad-hoc analysis of processes related to deficiencies identified via auditing processes.
Perform external delegation audit function (vision & dental providers) of audit program relative to claims payment
Manager, Claims (Medicare)
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 complianc
