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

• 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.

Skills / Requirements

Appeals Nurse Coordinator will assist the Appeals Manager and the Medical Director in the review of medical records submitted for appeals by providers due to adverse determination.  Utilize Milliman Care Guidelines and Medical Affairs departmental policies for medical necessity and level of care determination.  Utilize 3M Coding and reimbursement guideline for DRG assignment.  Provides written response of the outcome of the appeals finding to the appealing provider.  Assists in the ongoing development and maintenance of a database for tracking, trending and reporting appeals cases.
 

Qualifications:


Registered Nurse, current Texas License

1 year experience in NICU /Pediatric and or OB in acute care setting or MC

Computer with knowledge of Word, Excel, Access and Outlook


Exceptional Writing and Grammar, Above Average Verbal (Heavy Public Contact), Writing /Composing (Correspondence / Reports)


Analytical,  Medical Terms, P.C.,  MS Word,  MS Excel, MS Access

Work Schedule:       Flexible       

Strong written and verbal communications skills.

Application Instructions

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