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.

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 Resolutions Analyst II supports the review and resolution of complex payment disputes by determining the root cause of issue including in depth research and response to project related disputes; preparing written responses to appeals and reconsideration decisions, receipt of complex system-aid tickets, call tracking and web related inquiries to remediate impacted claims.    This position works urgent and priority requests, works in tangent with leaders to support testing and training initiatives.  The Claims Resolutions Analyst II utilizes payment experience and problem solving skills to determine and resolve outcomes in a timely manner.

MINIMUM QUALIFICATIONS:

1. Education/Specialized Training/Licensure:

  • Bachelor's degree or 4 years' claims adjustment experience in lieu of degree.

2. Work Experience (Years and Area):

  • 5 years of claims research, resolution or analysis of reimbursement methodologies experience. 

3. Management Experience (Years and Area): N/A
4. Software Operated: Microsoft Office (Word, Excel, Outlook)
5. Other Requirements:
Demonstrate sound analytical problem-solving and documentation skills.
Ability to speak, listen and write effectively, resolve problems and work independently to deliver excellent quality outcomes
Quick learner with the ability to adjudicate professional and facility claims, applying appropriate reimbursement methodologies.
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)
Team player with the ability to establish and maintain effective working 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:
Advanced Training Specialty: Bachelor¿s degree preferred

4. Work Schedule: Flexible, Overtime

RESPONSIBLE TO: Supervisor/Manager

EMPLOYEE SUPERVISED: N/A

Application Instructions

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