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 Customer Service Advocate II is a position within the Community Health Choice Customer Service Center that is primarily responsible for, but not limited to responding to incoming hotline inquiries as they relate to benefits and eligibility verification, claim status (with the ability to identify if a claim requires reconsideration), authorization status, and complaints, accurate documentation recording of all calls; effective follow-up of calls, as required; and proper electronic routing with effective documentation skills while maintaining confidentiality per HIPAA guidelines.


JOB SPECIFICATIONS AND CORE COMPETENCIES

Essential Functions
40% Ability to respond effectively and timely to inbound calls regarding benefits and eligibility, claims processing status, and authorization status. For those calls pertaining to claims inquiry, the Customer Service Advocate will effectively handle questions and document transactions in the proper claim modules, provide first call resolution, when possible, by identifying problems and providing solutions, submitting adjustment reconsideration request when appropriate, and identify and track trends and report them to the appropriate manager for resolution.
40% Maintains a working knowledge of the claim systems and accurately enters the required information into the designated Customer Relationship Management system (CRM), while adhering to departmental and organizational policies and procedures.
Marginal Functions
15% Maintains a professional behavior and exhibit excellent interpersonal skills.
5% Other Duties as assigned

Reports to Position Title: Customer Svc Center Supervisor
Employees Supervised Titles: N/A


MINIMUM QUALIFICATIONS:
Education/Specialized Training/Licensure:

  • High School diploma or GED or equivalent  

Work Experience (Years and Area):

  • 2 years relevant work experience of which: 1 (one) year of health care / plan, or other related experience.
  • Cross-functionality in Claims and Authorization Status, Benefits and Eligibility. for at least two (2) lines of business for all Customer calls and/or electronic communication.


Management Experience (Years and Area): N/A

Software Proficiencies: Microsoft Office (Word, Excel, Outlook)

Other: Ability to work independently under minimal direction. Moderate to advanced
computer knowledge required.

COMPETENCIES

Organizational Core Competencies:  All employees are responsible for understanding and demonstrating Community Health Choice core competencies:
Customer Focus
Reliability and Dependability 
Honesty & Integrity 
Achievement Orientation 
Change Management 
Team Work 
Problem Analysis
Attention to Detail
Analytical Thinking
Responding Sensitively
Above Average Verbal
Bilingual: Spanish or threshold language preferred


INTERPERSONAL SKILLS
Ensures all interactions are conducive to developing and maintaining a cooperative and productive working environment (both internally and externally).
Maintains self-control and conducts activities in non-adversarial manner

Application Instructions

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