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:

Actively participate in HEDIS projects for the organization as a nurse auditor. Assist team with data analytics to assure accurate and complete quantitative analysis of HEDIS data. Be familiar with and act as a resource for the organization regarding NCQA HEDIS and CMS QHP Measures Technical specifications, including RADV. Collaborates with teams regarding workflow process improvement, document management, and abstraction education as it relates to HEDIS projects. Responsibilities include monitoring, tracking, trending, analyzing, and reporting all data, performance measures, and other required information requested by the Health and Human Services Commission (HHSC), Centers for Medicare and Medicaid Services (CMS), Texas Department of Insurance (TDI), or any other accrediting or regulatory bodies. Monitors data and action plans as they relate to projects/programs overseen by the HEDIS team.

JOB SPECIFICATIONS 

Conduct provider medical record audits, abstraction and over read reviews to ensure accurate CMS payment and to ensure accurate reporting & monitoring of key NCQA standardized performance measurement activities (HEDIS).

Participate in year-round comprehensive medical records analysis and clinical data analysis, including data quality, provider documentation, coding patterns, record retrieval and targeted solutions for HEDIS. Maintain a database for tracking, trending, and reporting HEDIS, including HHS-RADV.

Responsible for facilitating and helping with the implementation of new and existing healthcare HEDIS strategies for improving internal HEDIS monitoring programs Provide educational feedback to providers regarding risk adjustment and quality of care improvement.

Be familiar with HEDIS to develop into being a subject matter expert for risk adjustment (HHS-RADV) and HEDIS measure technical specifications. Participate as SME and maintain exceptional teamwork with both external partners and internal departments. 

Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and/or participating in professional societies.

Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plans.

Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness, and caring service

Other duties as assigned.


MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure: Registered Nurse in the state of Texas, BSN preferred
Work Experience (Years and Area): Two years of experience working in a managed care environment with a strong working knowledge of ICD -10 coding. Experience in Marketplace or Medicare Advantage Plan to include experience in Risk Adjustment preferred.
Software Proficiencies: Microsoft Office (Word, Power Point, Excel. Outlook)

Reports to Position Title: Manager HEDIS (CHC)

Application Instructions

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