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
* 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 Claims Adjustment Analyst II supports the review and resolution of complex level payment disputes including corrected claims; retro authorizations, incorrect denial requests, reconsiderations and provider payment appeals in a timely manner. This position is responsible for processing medical and dental claims, using industry standard practices for medical claims processing. The Claims Adjustment Analyst II applies relevant rules and regulations specific to coding, providers, plan benefits, contracts, state and federal guidelines as well as Community Health Choice's policies and procedures.
MINIMUM QUALIFICATIONS:
1. Education/Specialized Training/Licensure: High school Graduate
2. Work Experience (Years and Area): 4 years of claims adjustment experience in multiple lines of business (both Marketplace and HHSC.)
3. Software Operated: Microsoft Office (Word, Excel, Outlook)
Other Requirements:
- Sound analytical problem-solving and documentation skills.
- Ability to speak, listen and write effectively.
- Quick learner with the ability to adjudicate professional and facility claims, applying appropriate reimbursement methodologies.
- Ability to problem solve and work independently.
- Team player with the ability to establish and maintain effective work relationships
SPECIAL REQUIREMENTS:
1. Communication Skills:
Writing /Composing: Correspondence / Reports
2. Other Skills: Analytical, Mathematics, Medical Terminology, Research, MS Word
3. Advanced Education: N/A
4. Work Schedule: Flexible, Overtime
RESPONSIBLE TO: Supervisor/Manager
EMPLOYEE SUPERVISED: N/A