Business Plan, Community Health, Compensation and Benefits, DOS Operating System, Data Entry, Data Quality, Database Administration, Diabetes, Diagnosis-Related Group (DRG), Financial Support, Health Plan, Healthcare Quality, Hospital, Insurance, Managed Care, Medicaid, Medical Assistance, Medical Terminology, Microsoft Excel, Microsoft Office, Microsoft Outlook, Microsoft Word, Nonprofit, Nursing, Operations Planning, Organizational Skills, Process Improvement, Risk, Utilization Review Accreditation Commission (URAC)
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
Childrens 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 Profile
JOB SUMMARY
The Appeals Coordinator is responsible for intake of all forms of correspondence for the medical appeals team to process for medical appeals, post service claim and retrospective reviews that are assigned to a nurse to facilitate medical necessity review. This position is responsible for the accurate recording of all provider data elements into a database.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Reviews the documentation received for timeliness of requests. Data entry of all provider appeals, Fair Hearings, IROs, retrospective reviews, and claim appeal inquiries into the appeals database ensuring accurate recording of all provider data elements.
Data entry of provider appeals, retrospective reviews, and inquiries received in appeals department and preparation of documents for Laserfiche and scanning as warranted.
Maintains an accurate data base of all appeals and tracks responses due, correctly identify the type of review such as adverse determination, LOC, MN, DRG and DOS.
Daily monitoring and effective follow-up of provider claim appeals and inquiries to ensure closure within 30 days of receipt.
Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans, and other duties as assigned.
Reports to Position Title: Sr. Manager Complaints & Appeals
QUALIFICATIONS:
Education/Specialized Training/Licensure: High School Diploma required.
Work Experience (Years and Area): Two (2) years insurance related job experience required.
Medical terminology or medical assistant experience preferred
Software Proficiencies: Microsoft Office (Word, Excel, Outlook)
Benefits & EEOC
Community employees benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.
Community is an Equal Opportunity Employer.
Harris Health's benefits program is designed to provide you with more flexibility and choices in meeting your specific needs. Harris Health's benefits program allows you to protect your income in case of illness, death and disability, and to help you save for retirement.
It is the policy of Harris Health to provide equal opportunity for all applicants for employment regardless of political affiliation, race, color, national origin, age, sex, religious creed or disability. Applicants may request any reasonable accommodation(s) to participate in the application process.H
Harris Health System
Harris Health is a nationally recognized health system comprising three teaching hospitals and an extensive network of ambulatory care centers serving the people of Harris County, Texas, since 1966. Staffed by the faculty, fellows and residents from two nationally ranked medical schools, Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth), Harris Health is the first healthcare system in Houston to receive the prestigious National Committee for Quality Assurance (NCQA) designation for its network of patient-centered medical homes.
Each year, Harris Health provides more than 1.8 million total outpatient visits through its more than 40 ambulatory care facilities. Additionally, Harris Health sees more than 177,000 emergency visits at its Level 1 and Level 3 trauma centers and 35,000 hospital admissions through its three hospitals: Ben Taub, LBJ and Quentin Mease. Established by voter referendum to enhance the level of charity care available in the community, Harris Health System has often received national recognition for serving those in need and for its achievements in operational excellence, such as being named to the 2011, 2012, 2013 and 2014 Most Wired Hospitals lists by the American Hospital Association's Hospitals & Health Networks magazine.
Additionally, Harris Health System is pleased that each of its three hospitals: Ben Taub, Lyndon B. Johnson and Quentin Mease - achieved Pathway to Excellence designation by the American Nurses Credentialing Center.
5,000 to 9,999 employees
https://www.harrishealth.org/en/pages/home.aspx