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 
The Associate Medical Director provides support for Community Health Choice's medical management programs. This includes performing medical necessity reviews, with peer-to-peer interactions as needed; appeals of adverse determinations; some clinical input and oversight for Care (Disease) Management, Quality Improvement, Credentialing, and Preventive Medicine programs; working with Provider Relations to maintain and improve relationships with the provider community; and other duties as assigned.

JOB SPECIFICATIONS AND CORE COMPETENCIES
Performs medical necessity review of authorizations, as well as appeals of adverse determinations (if indicated) utilizing evidence-based guidelines and/or plan specific policies. Authorization reviews include pre-certification, retrospective, concurrent, and claim reviews.
Performs benefit (not covered, out-of-network, etc.) reviews and appeals utilizing appropriate line of business benefits.
Performs peer to peer interventions for all aspects of medical management.
Provides clinical oversight support for care (disease) management, quality improvement activities, credentialing, and preventive medicine, as directed.

Provides clinical oversight support for medical management activities related to utilization management, case management, disease management, quality improvement, credentialing, and preventive medicine.
Reviews quality referred issues, performs focused reviews and recommends corrective actions.
Reviews legal referred issues and provide recommendations as requested.
Reviews complaint cases as directed with resolution recommendations as requested. Examples include complaints from OIG, member complaints, etc.
Provides clinical support on plan operational policies, processes, and procedure such as
payment Policy Committee as directed by VP Sr. MD
Provides clinical support on interdepartmental projects:
Assist in developing an effective and efficient Prior Authorization list for each line of business.
Assist in reviewing explanation of coverage for each line of business.
 

Other duties as directed
Develops, reviews, and implements plan medical policies and other medical decision-making policies or procedures. This may include aiding in development of utilization management or disease management medical policies or job aids.
Develops physician education with respect to clinical issues and policies through letters and articles in the provider newsletter and other publications.
Develops written information to members through letters and articles in member newsletters and other publications.
Provides clinical guidance and support to initiatives that address public health issues.  (previous ex. COVID back to work initiative; syphilis epidemic).
Identifies and develops opportunities for innovation to increase production, service and clinical quality.
Participation on Community panels as directed such as the Member Complaint Appeal Panel, etc.
Attends or chairs committees as directed such as Fraud, Waste and Abuse, Quality Improvement Committee, and others to achieve medical utilization cost and quality objectives, as directed. 
Assist in establishing collaborations with community organizations 

Assists the Vice President Sr. Medical Director (VP Sr. MD) in working with Provider Relations to maintain and improve relationships with contracted providers, including issues related to claim payment, chronic care management, and general utilization management. This may also include visits to high volume providers, and review of provider incentive plan payments.

Actively contributes to achievement of departmental goals, as identified in department's annual business plan, including specific departmental process improvement plans, and other duties as assigned.

Reports to Position Title: Vice President Sr. Medical Director

QUALIFICATIONS: 
Education/Specialized Training/Licensure: M.D. or D.O required
Current and unrestricted license in Texas required
Must live in Greater Houston area
No current sanction from Federal or State Governmental organizations
Able to pass credentialing requirements. 

Current and ongoing Board Certification in an approved ABMS Medical Specialty preferred.
Primary Care Specialties
Master's degree in public health, Business Administration or Medical Administration preferred

Work Experience (Years and Area): Eight (8) years active clinical experience 

Management Experience (Years and Area): N/A 
Preferred: one (1) year of administrative experience in management of a private or group practice, facility, or other similar administrative experience such as physician reviewer or medical director in a facility or health plan preferred.

Software Proficiencies: Proficient in office software; must be able to become proficient in clinical information systems required.

Job Family/Job Title Competencies
Problem Analysis
Attention to Detail
Motivated
Decision Making

List any additional competencies not indicated above:
Strong verbal and written communication skills
Ability to work independently.
Self-discipline and time management skills
Technology proficiency: comfort with learning and using digital tools.
Ability to work effectively in cross functional teams.

INTERPERSONAL SKILLS 
Interact successfully in a team environment.
Communicate effectively with individuals from varied experiences, perspectives, and backgrounds.
Exemplify emotional intelligence and cultural competency.

WORK ENVIRONMENT OR PHYSICAL ABILITIES REQUIRED OF THE JOB 
Remote (with ability to use hotel cubicles) except for mandatory in-person meetings such as company-wide Town Hall meetings, etc. as scheduled.
Hoteling available in Community's office building when desired or unable to work remotely (ex. no internet, issues with computer, etc.).
Office setting with low partitions and open floor plan. Office is in a high-rise building.
Close Paper/Computer work

Application Instructions

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