Job Abstract

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 Senior Provider Relations Representative is office-based and is responsible for resolving Physician, Hospital, Ancillary, and Physician organization (Provider) focused issues including, but not limited to educational needs, contract verification, participation status, claims payment discrepancies, interaction with Community's provider portal, and questions regarding Community's process for obtaining authorizations. The Senior Provider Relations Representative exhibits good communication and interpersonal skills; maintains a working knowledge of the designated QNXT referral, claims, eligibility, and provider modules, as well as all CACTUS modules, and serves as the primary party responsible for responding to inquiries referred to Provider Relations. The Senior Provider Relations Representative ensures that new Providers receive the required initial education materials, i.e., Provider Manual, Quick Reference Guides, etc.; supports the Provider Engagement Representatives and Provider Relations Representatives by monitoring and reporting educational needs identified through web inquiries, reports, and other analytical measures; may provide guidance or expertise to fellow team members. Works closely with management or takes the lead to create, maintain and update provider communications including, but not limited to provider notices, provider manuals, quick reference guides, and orientations as required by URAC, NCQA, TDI, HHSC, CMS, and other regulatory agencies. Collaborates with leadership, co-workers, and staff in other departments to achieve departmental and organizational objectives.

MINIMUM QUALIFICATIONS:

1. Education/Specialized Training/Licensure: High School or equivalent required. BA/BS in Business preferred
2. Work Experience (Years and Area): 5 years' experience in managed care (Provider Relations/Services; Claims Adjudication, Medical Coding, Contracting)
3. Management Experience (Years and Area): N/A
4. Software Operated: Microsoft Office (Word, Excel, Outlook and PowerPoint), QNXT and CACTUS systems preferred

SPECIAL REQUIREMENTS: (Check Applicable Areas)

1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Writing /Composing: Correspondence / Reports

2. Other Skills: Medical Terminology, Statistical, MS Word, MS Excel, MS PowerPoint

3. Advanced Education:

Bachelor's Degree Major: Preferred

4. Work Schedule: Flexible

RESPONSIBLE TO: Director

 

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