Lead Utilization Management Coordinator

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.

Under the direction of the Sr. Manager Utilization Management, the incumbent shall serve as the first line coach to the UM Precertification and Concurrent Review Coordinators. The Lead UM Coordinator must be familiar with Community’s lines of business, be an expert on template creation, and can quickly and accurately resolve any issue raised by the coordinators or internal/external stakeholders.

Serve as the first line coach to the UM Coordinators. As an on‑the‑floor floater, the Lead UM Coordinator has the experience and overall CHC product acumen, knowledge of template creation to quickly and accurately resolve issues raised by a UM Coordinator and/internal and external stakeholders. Demonstrates the team desire for turnaround compliance and process improvement, sharing and supporting tasks and training with the UM Leadership team as well as performing UM Coordinator duties.

Data entry of admissions, notification of deliveries, sick newborns, and other services. Obtains all pertinent information and medical codes related to the admission, transfer, out‑of‑network provider, route of transport, type of service, type of durable medical equipment and other key information. Assists in monitoring reports and refers to appropriate UM Nurse or Manager. Responding and forwarding calls efficiently and in a timely and professional manner to appropriate nursing staff, medical staff, or other departments when appropriate.

Review and process fax and telephone requests to meet departmental key metrics and productivity standards, maintain established threshold for case data entry accuracy within compliance time frames. Actively contributes to achievement of departmental goals, as identified in the Department’s annual business plan, including specific departmental process improvement plans and other duties as assigned.

Education/Specialized Training/Licensure:
High School Diploma or GED required

Two (2) years college education preferred.

Work Experience (Years and Area):
Four (4) years experience in healthcare setting such as a medical clinic, hospital, or managed care. Associate or bachelor’s degree may be used in lieu of experience.

Medicaid Coding preferred.

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