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: 
Serves as the point of contact for Third Party Administration (TPA) services provided to key clients and the relations manager for key subcontractors/delegated entities. 

Negotiates or assists the Director of Network Administration with TPA service and delegated entities contracts and/or related downstream provider agreements.  As needed, collaborates with internal departments such as Compliance, Contracting, Provider Services, Configuration, Claims, Finance, Analytics, Legal Affairs, Medical Affairs, and Purchasing to ensure input into TPA services and delegated entities contracts prior to execution for optimal administrative efficiency, as well as accurate implementation and on-going reporting.   Accountable for maintaining the relationship with TPA clients and delegated entities, ensuring contract compliance and resolution of various issues related to services, which may include, but are not limited to claims payment, invoice generation and payment receipt, provider access & availability, member/provider complaints and data reporting.


MINIMUM QUALIFICATIONS:

  1. Education/Specialized Training/Licensure: 
    • Bachelor's Degree required. 
    • Four (4) years of equivalent work experience may substitute for degree requirement.    
  2. Work Experience (Years and Area):
    • Seven (7) plus years in healthcare with at least Five (5) years of experience in Managed Care contracting, Provider Relations, or Third-Party Administration relations.
  3. Equipment Operated:
    • PC, Phone, Fax, Scanner


SPECIAL REQUIREMENTS: 
1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Writing/composing Correspondence Reports
2. Other Skills:
Analytical
Mathematics
Medical Terminology 
P.C.    
Research
Statistical
Word Processing
3. Work Schedule: Flexible


 

Application Instructions

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