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

JOB SUMMARY: 

The Certified Medical Coder will lead administrative/operational support tasks that require independent review and judgment relative to coding concerns. The Certified Medical Coder will review claims data to ensure that assigned codes and supplies meet state, federal and health plan guidelines.   The certified medical coder will conduct research including review of medical records and correspond with the appropriate claims or medical management staffing personnel. 

JOB SPECIFICATIONS 

Essential Functions
25 % Responsible for assisting with appeals and payment disputes /denials.  The coder will review clinical documentation utilized in the decision-making process to support the validity of codes billed
25 % Act as knowledge expert to service claims operations with follow up and recommendations related to claim denials
20 % Collaborate with Claims Unit and Medical Management as needed to ensure appropriate documentation and coding was submitted.  
20 % Remain abreast of current Centers for Medicare and Medicaid Services, (CMS) requirements as well as Correct Coding Initiative, (CCI) edits, Hospital Acquired Conditions, (HAC's) and when applicable, National Coverage Determinations, (NCDs) and Local Coverage Determinations, (LCDs,) including the addition of appropriate modifiers to ensure a clean claim the first time through

Marginal Functions
5 % Perform routine and ad-hoc analysis of processes related to deficiencies identified via coding review projects
5 % Keep team abreast of new coding conventions, changes in current coding conventions, and provide feedback on coding trends

Reports to Position Title: Sr. Manager, Claims Quality Support
Employees Supervised Titles: N/A


MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure: High School diploma, GED or equivalent; Bachelors preferred.

Certification:  Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) Certifications Candidate should obtain the additional certification within 12 months of employment.

Work Experience (Years and Area): Bachelors and 2 - 4 years relevant work experience; or 6-8 years of recent coding experience in lieu of bachelors degree  
5 Years of ICD-10 experience (Preferred)
Experience with a health plan or Third-Party Administrator (Preferred)

Interpersonal Skills: Excellent communication skills and the ability to interact with others effectively.  
Software Proficiencies: Microsoft Office (Word, Excel, Outlook) 

Other: Strong critical thinking and analytical skills required. 


Job Family/Job Title Competencies:
Problem Analysis
Analytical Thinking
Organizational Sensitivity
Results Oriented
Above Average Verbal 
Writing /Composing 
Medical Terminology


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

Application Instructions

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