Details
Posted: 11-Jan-26
Location: Houston, Texas
Type: Full Time
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 Certified Medical Coder will lead administrative and operational support tasks that require independent review and judgment relative to coding concerns. The Certified Medical Coder performs reviews of claim lines flagged by Community's Special Investigation Unit against medical records to determine the appropriateness of the claim. The coder will review claims data to ensure that assigned codes and supplies meet state, federal, and health plan guidelines. The Certified Medical Coder will conduct research, including a review of medical records, and correspond with the appropriate claims or medical management staffing personnel.
JOB SPECIFICATIONS AND CORE COMPETENCIES:
SIU Prepayment Review and Claims Evaluation
Perform SIU Prepayment Reviews, including medical record reviews, identifying providers for prepayment review, and evaluating compliance.
Update the cost tracker for prepayment review activity.
Process and adjudicate claims received for reimbursement to providers based on SIU review as needed.
Appeals and Payment Disputes Support
Assist with appeals and payment disputes or denials.
Review clinical documentation used in decision-making to support the validity of billed codes.
Collaborate with Claims Operations and Medical Management to ensure appropriate documentation and coding were submitted.
Regulatory and Coding Compliance
Maintain current knowledge of Centers for Medicare and Medicaid Services (CMS) requirements.
Apply Correct Coding Initiative (CCI) edits, Hospital-Acquired Conditions (HACs), and applicable National and Local Coverage Determinations (NCDs/LCDs).
Ensure use of appropriate modifiers and compliance with all regulatory coding guidelines.
Provider Inquiry and Communication Management
Field provider inquiries related to prepayment review.
Create prepayment review provider letters and handle responses in a professional and timely manner.
Claims Operations Collaboration and Support
Serve as a knowledge expert to assist Claims Operations.
Provide follow-up and recommendations related to claim denials to ensure resolution and prevent recurrence.
Actively contributes to the achievement of departmental goals, as identified in the Department's annual business plan, including specific departmental process improvement plans. Other duties as assigned.
Reports to Position Title: Manager, Special Investigation Unit
QUALIFICATIONS:
Education/Specialized Training/Licensure: High School diploma, GED, or equivalent; Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification required.
Bachelor's degree preferred.
Work Experience (Years and Area): 6-8 years of recent coding experience (in lieu of bachelor's degree) required.
Experience with a health plan or Third-Party Administrator preferred
Management Experience (Years and Area): N/A
Software Proficiencies: Microsoft Office (Word, Excel, Outlook)
Other: Strong critical thinking and analytical skills required.
Job Family/Job Title Competencies:
Problem Analysis
Analytical Thinking
Attention to Detail
Results Oriented
Above Average Verbal
Writing /Composing
Medical Terminology
INTERPERSONAL SKILLS
Excellent interpersonal, written and verbal communication skills required. Ability to maintain strict confidentiality.
