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: Responsible for receipt, management, investigation and resolution of Member and Provider regulatory complaints from CMS, HHSC, TDI and any other regulatory body.  Investigates and responds to Health Insurance Casework System (HICS) complaints. Position is responsible for maintaining appropriate accreditation for Health Plans as required by regulatory agencies and management of the regulatory complaint resolution staff. Provides direct support to the Chief Compliance Officer, focusing on the ongoing adherence to accreditation standards; review and monitoring of control processes across the product areas and functions within the organization to assure compliance with regulatory complaint responses. 

    MINIMUM QUALIFICATIONS:
  • Education/Specialized Training/Licensure: Bachelor's Degree.
  • Master's Degree preferred
  • Certification in Healthcare Compliance a plus
  •  Work Experience (Years and Area): Five years of experience in health care accreditation with previous experience in a managed care organization.
  •  Management Experience (Years and Area): 5 years management experience in a healthcare setting
  • Equipment Operated: Standard Office Equipment

    SPECIAL REQUIREMENTS: (Check Applicable Areas)
     
  • Communication Skills: 
  • Above Average Verbal (Heavy Public Contact) 
  • Exceptional Verbal (e.g., Public Speaking) 
  • Bilingual Skills Required? No 
  • Writing /Composing Yes   (Correspondence / Report
  • Other Skills:
    analytical 
    Medical Terminology 
    Statistical 
    Typing 
    wpm 
    PC 
    MS Word 
    MS Excel 

    Advanced Education:
     
  • Advanced Training Specialty: Certification in Health Care Compliance Preferred
  • Bachelor's Degree Major: BA/BS 

 Work Schedule: Flexible 

Other Requirements:

  • Knowledge of Medicare Advantage, MMP, D-SNP, and STAR+PLUS
    Strong communication skills
    Ability to organize tasks and work independently
    Strong attention to detail and deadlines

Application Instructions

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