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

STAR +PLUS Appeals Nurse assists in the review of medical records submitted for appeals by providers due to adverse determination. Utilize evidence-based criteria, regulatory guidelines and Medical Affairs departmental policies for medical necessity and level of care determination. Provides written response of the outcome of the appeals finding to the appealing provider and member. Assists in the ongoing development and maintenance of a database for tracking, trending and reporting appeals cases.

JOB SPECIFICATIONS

Essential Functions

Reviews and provides resolution of STAR+PLUS Appeals, per regulatory guidelines to providers for cases submitted for appeals review due to adverse determination. Ensures that all resolution letters are put out for mailing within 2 business days of determination being rendered.

Accurately evaluates all cases by utilizing evidence-based criteria and Medical Affairs departmental policies for medical necessity and level of care. Notifies the Claims department the same day of overturned adverse determination requiring adjustments. Logs and closes out all cases in the appeal clinical platform after resolution the same day.

Providing written feedback to senior leadership to improve inter-rater reliability.

Assists in the ongoing development and maintenance of the database for tracking, trending and reporting all data as related to adverse determination received by CHC, by providing feedback to senior leadership.

Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plans.

Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.

Marginal Functions

Other duties as assigned.

Minimum Qualifications

Education/Specialized Training/Licensure: Registered Nurse, current Texas License required.

Work Experience (Years and Area): One (1) year of experience utilizing evidence-based criteria in medical reviews; One (1) year in acute care setting or managed care setting , 1-3 years STAR+ PLUS experience required.

Appeals Experience Preferred.

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

Community Health Choice

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STAR+PLUS Appeals Nurse RN