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 Claims Adjustment Analyst supports the review and closure of payment disputes including: corrected claims, retro authorizations, and incorrect denial requests in a timely manner. This position is responsible for processing medical claims, using industry standard practices for medical claims processing. The Claims Adjustment Analyst 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 Diploma, GED or Equivalent.

2. Work Experience (Years and Area): One (1) year of high performance claims processing analyst experience or Two (2) years of Claims Adjustment experience.

3. Management Experience (Years and Area): N/A

4. Software Operated: Microsoft Office (Word, Excel, Outlook, etc.)

5. Other Requirements:

  • Analytical problem solving and documentations; Reimbursement methodologies; ability to adjudicate.
  • Ability to speak, listen and write effectively.
  • Team player with the ability to establish and maintain effective work relationships.


SPECIAL REQUIREMENTS: (Check Applicable Areas)

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

Application Instructions

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