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 Director provides strategic leadership in the development, direction, execution, and evaluation of an effective provider performance program. The Director is responsible for assuring the program supports the delivery of quality and growth outcomes through collaborative, innovation-focused relationship with participating practice groups.  The goal of this department is to optimize practice performance in a value-based and/or risk-based environment and assess against industry standards.

In addition, the Director develops systems to ensure effective coordination between all functions within the health plan to meet the needs of the network providers.  Establishing effective processes within the health plan operations.


JOB SPECIFICATIONS AND CORE COMPETENCIES

Strategic Planning:

  • Collaborates with key departments to develop provider performance targets that meet the strategic objectives of the organization.
  • Develops and maintains a Community Practice Transformation Playbook.
  • Establish innovations to drive provider practice performance.
  • Identify improvement opportunities that will drive outcomes for providers and the organization. 
  • Monitors and reports significant developments occurring within the provider community and assists in developing a strategic plan to mitigate risks and capitalize on opportunities.
  • Establishes and updates as needed CHC provider performance policies and procedures and CHC provider contractual materials.
  • Monitors the outcomes metrics for the network's performance.


Departmental Management:

  • Assists in the development of annual departmental budgets and monitors expenditures to meet administrative cost targets.
  • Ensures all related operations, communications, and daily interactions with providers remain compliant with regulatory and accreditation standards.
  • Ensures timely and accurate submission of related regulatory and compliance reports associated with the provider performance.
  • Monitors the provider landscape to ensure Community¿s is competitive.

Cross-functional Duties:

  • Works with the Finance, Analytics, Quality, Provider Operations, Medical Affairs, and Executive Team as needed to make essential data-driven decisions.
  • 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:

  • BA/BS; 4 years equivalent work experience may substitute for degree requirement.
  • Work Experience (Years and Area): 7 years in healthcare, with at least 5 years experience in Providers/Managed Care Contracting. Medical contract negotiations experience.
  • Health Plan experience, Experience within the Houston market.


Management Experience (Years and Area): 4 years direct supervision experience required.

Software Proficiencies: Microsoft Office Suite

Other: Must have car and valid Texas Driver¿s license Contracting experience with hospital and physician practice (group practice & solo practitioner) required. Developing and implementing strategic objectives for the contracting function. Experience implementing provider incentive programs and pay-for-quality programs, claims payment and CRM systems. Demonstrated ability to manage and develop staff in medical contract negotiation.

Experience with QNXT and Salesforce.

Application Instructions

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