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

Clinical effectiveness is a top system priority for achieving Communitys safety, quality, and cost strategy by reducing costs associated with variations in clinical review and service coordination functions. This position serves as a subject matter expert and change agent that can facilitate clinicians and lead consensus around operational processes and evidence-based care.

JOB SPECIFICATIONS AND CORE COMPETENCIES

  • Functions as a SME to the UM or CM team for day-to-day operations and has oversight for clinical process redesign and clinical consensus building to reduce unwarranted clinical process variation and improve outcomes. Collaborate and integrate new initiatives with existing ones, which means that the job may require multiple project assignments depending on work required and bandwidth.
  • Works collaboratively with multi-disciplinary teams and subject matter experts to develop and lead evidence based and consensus driven projects while leading and facilitating clinical effectiveness initiatives extensively utilizing change management approaches and resources.
  • Partners to create tools and tactics to shape and hardwire standardization efforts, training, and review processes or care partnering with L&D to deliver effective tools and resources to the UM teams. Champion, lead, and collaborate on educational initiatives relevant to the project deliverables, which may include oversight of the development and execution of rigorous training materials/plans.
  • Implementation of clinical effectiveness initiatives-propose, and direct implementation of clinical effectiveness initiatives based on current state evaluation, cause for action, evidence review, data and gap analysis, and oversight for development of a project plan and strategy for implementation. Assess potential challenges and barriers to project design and implementation plan. If unable to resolve personally, collaborate with the appropriate leaders and teammates to facilitate resolution. Communicate and collaborate with key stakeholders to ensure successful implementation of process and change management solutions. Facilitation and Participation within Process Improvement Initiatives.
  • Provide coaching to leaders, physicians, managers, and front-line staff ensuring effective implementation of new processes, guidelines, and deliverables.
  • Provides support for Medical Affairs to create and maintain CM clinical pathways.
  • Actively lead teams and provide individual contribution in problem solving efforts on selected projects to decrease variation in practice.
  • Collaborate with Information Systems and other relevant project teams on application selection(s), design, testing and training.
  • Actively contributes to achievement of departmental goals, as identified in Department¿s annual business plan, including specific departmental process improvement plan, and other duties as assigned.


QUALIFICATIONS:

  • Education/Specialized Training/Licensure:
  • Bachelors degree in nursing with Texas RN license (or compact including Texas) is required.
  • Platform migration and prior authorization catalog development experience preferred.
  • Work Experience (Years and Area): Minimum of Five years of work experience including health plan UM or CM.
  • Work experience with health information systems.
  • Management Experience (Years and Area): 2 years of either management, supervisory role, or project management experience.


Software Proficiencies:

  • Microsoft Office
  • Visio, SharePoint

Application Instructions

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