Performance Adherence Specialist - Harris Health System

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 SUMMARY

The overall objective of the Performance Adherence Specialist is to monitor and report the program outcomes for the STAR, STAR+PLUS, Marketplace and DSNPs contracts.

The Performance Adherence Specialist will be responsible to monitor and report the activities of Service Coordination, Case Management and Utilization Management programs, to ensure all operational activities to include quality metrics, contractual regulatory and operational reporting requirements are met for STAR, STAR+ Plus, DSNP and Marketplace.

The Performance Adherence Specialist is responsible for auditing and monitoring the performance of staff to ensure the delivery of best practices, and to ensure state deliverables are timely. The Specialist will utilize training and auditing tools to monitor service coordination for all lines of business to ensure adherence to policy and procedures, regulatory requirements, and accreditation standards.


JOB SPECIFICATIONS AND CORE COMPETENCIES

• Monitors Medical Affairs performance for all lines of business for adherence to policies and procedures, regulatory requirements, and accreditation standards.
• Collaborates with internal and external stakeholders to respond to regulatory agency requests (ie. HHSC) for monthly and annual reporting.
• Track and report on metrics developed within the Model of Care for all lines of business.
• Utilizes approved auditing tools and conducts monthly audits on all Medical Affairs staff.
• Provides reports and feedback to management regarding performance of Medical Affairs staff regarding adherence to policies and procedures, regulations and standards.
• Identifies opportunities for improvement and uses a process improvement cycle to recommend solutions for identified problems.
• Proactively identify risks and mitigation activities thus ensuring contract requirements are met.
• Monitors regulatory requirements on an ongoing basis.
• Recommends modifications to training materials when systematic deficiencies are identified.
• Recommends updates to policies and procedures to reflect changes to regulatory and accreditation standards.

Other Duties as assigned.

QUALIFICATIONS:

• Education/Specialized Training/Licensure: High School diploma required.
• Associate degree or higher preferred.
• Work Experience (Years and Area): 5 years health care setting, including managed care organization.
• Auditing/compliance experience preferred.
• Software Proficiencies: PC Microsoft Office (Word, Excel, Outlook)