Claims Arbitration Liaison
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
The Claims Arbitration Liaison serve as the liaison for health plan and provider disputes in an effort to resolve claims issues within the applicable timeframe. Tasks include but not limited to arbitration support, standard post claims adjustments based on TDI Arbitration adjustment request amounts and or agreed upon negotiated rates.
- High School Graduate, GED or equivalent.
- 6mo - 2 years of claims adjustment experience with professional, inpatient and outpatient claims for multiple lines of business (i.e. Marketplace, Commercial, Medicare, Medicaid) Claims Arbitration experience (preferred)
3. Management Experience (Years and Area): N/A
4. Software Operated: Microsoft Office Suite
5. Other Requirements:
Computer literate and basic knowledge of claims software usage.
Basic knowledge of medical procedures and terminology, medical CPT, ICD-10, DRG and Healthcare Common Procedure Coding System (HCPCS).
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: (Check Applicable Areas)
1. Communication Skills:
Writing /Composing (Correspondence / Reports)
2. Other Skills:
3. Advanced Education: N/A
4. Work Schedule: Weekdays, Flexible
5. Other Requirements: N/A
RESPONSIBLE TO: Supervisor/Manager
EMPLOYEE SUPERVISED: None
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Job Status: Full Time
Job Reference #: 166828