Claims Resolutions Analyst
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.
JOB SUMMARY: The Claims Resolutions Analyst supports the review and resolution of payment disputes including in depth research and response to project related disputes; preparing written responses to appeal and reconsideration decisions, receipt of complex sys-aid tickets, call tracking and web related inquiries. Tracking and trending of incorrect claims outcomes and work with department leaders to correct adjudication processes. The Claims Resolution Analyst will work urgent and priority requests, work in tangent with leaders to support testing and training initiatives. Additional tasks include corrected claims, retro authorizations, incorrect denial requests, and review of correspondence, reconsiderations, compliance related complaints, and provider payment appeal in a timely manner. The Claims Resolutions Analyst will utilize payment experience and problem-solving skills to determine outcomes. The Claims Resolutions Analyst will determine root causes and remediate impacted claims.
MINIMUM QUALIFICATIONS:
1. Education/Specialized Training/Licensure: High School Diploma, GED or Equivalent.
2. Work Experience (Years and Area): Five (5) years of professional and facility (inpatient/outpatient) claims payment experience or claims research, resolution or analysis of reimbursement methodologies experience.
3. Software Operated: Microsoft Office Suite
5. Other Requirements: Extensive knowledge of CMS and/or TMHP guidelines.
Claims Adjustment Analyst skills mastery; handle highest level of claim appeals and complaints; communicate with legal to secure determination; support arbitration and provider interest and penalty dispute process.
Sound analytical problem-solving and documentation skills.
Computer literate with 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).
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.
1. Communication Skills:
Writing /Composing (Correspondence / Reports)
2. Other Skills:
Analytical
Mathematics
Medical Terminology
Research
MS Word
3. Work Schedule: Weekdays, Flexible
RESPONSIBLE TO: Supervisor/Manager