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 Appeals Coordinator is responsible for intake of all forms of correspondence for the medical appeals team to process for medical appeals, post service claim and retrospective reviews that are assigned to a nurse to facilitate medical necessity review. This position is responsible for the accurate recording of all provider data elements into a database.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Reviews the documentation received for timeliness of requests. Data entry of all provider appeals, Fair Hearings, IROs, retrospective reviews, and claim appeal inquiries into the appeals database ensuring accurate recording of all provider data elements.
Data entry of provider appeals, retrospective reviews, and inquiries received in appeals department and preparation of documents for Laserfiche and scanning as warranted.
Maintains an accurate data base of all appeals and tracks responses due, correctly identify the type of review such as adverse determination, LOC, MN, DRG and DOS.
Daily monitoring and effective follow-up of provider claim appeals and inquiries to ensure closure within 30 days of receipt.
Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans, and other duties as assigned.
Reports to Position Title: Sr. Manager Complaints & Appeals
QUALIFICATIONS:
Education/Specialized Training/Licensure: High School Diploma required.
Work Experience (Years and Area): Two (2) years insurance related job experience required.
Medical terminology or medical assistant experience preferred
Software Proficiencies: Microsoft Office (Word, Excel, Outlook)
