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

The Sr. Director, Internal Audits is  responsible for overseeing all ongoing activities related to the development, implementation, and maintenance of Community's Audit Program. Oversee and manage efforts for the internal audit program that ensures the soundness of internal controls over key financial and operational processes, including IT General Controls. Responsible for oversight of the internal audit department staff and monitoring the Model Audit Rule (MAR) Compliance Program. Responsible. Plan and manage the audits related to oversight of the Delegated Entities (Delegation Oversight).  Responsible for planning and execution of for operational, compliance and ad hoc audits  throughout the organization   to ensure Community's operations and processes are compliant with laws and regulations. Responsible for validation audits to confirm implementation of Corrective Action Plans or Regulatory changes to processes within the organization. Ensure that audits cover all lines of business (Star, Marketplace, CHIP and D-SNP) either separately on in a clustered review.

Must maintain open lines of communication with internal partners, regulators, vendors and other internal or external partners to assure collaborative working relationships. Provides direct support to the Chief Compliance Officer, focusing on the ongoing monitoring of control processes across all product areas and functions within the organization. Assists Compliance Regulatory Affairs and Compliance Operations in the readiness preparation for external audits. Development of policies and procedures and corrective action plans to ensure that Community's Internal Audit, Risk Management and operational and compliance audit programs function efficiently and effectively.  Responsible for producing on  a monthly, quarterly and/or annually basis risk reports based on the data originating from audit results as well as from selected metrics from organization's Key Performance Indicators. Supports Enterprise Risk Management report production as directed by the CCO.

Presents audit and risk results the Regulatory Affairs Compliance Committee and Executive Compliance Committee.

Develop and maintain a professional team approach with both external and internal partners to achieve accurate results and the organizations strategic goals.

QUALIFICATIONS:

  • BA/BS degree (Masters preferred); CIA or CPA
  • Eight years previous experience in Compliance, Risk Management and/or Auditor role. Preferred experience in managed care organization.
  • Four years management experience in a healthcare preferably managed care organizations.

OTHER SKILLS:

  • Ability to maintain an attitude of independence and objectivity towards all internal and external partners.
  • Ability to organize tasks and work independently.
  • Knowledge of statistics and sampling methodology.
  • Knowledge of billing (professional and facility) and coding (CPT, ICD-10, HCPCS, DRG)
  • Strong attention to details and deadlines.
  • Strong communication skills.





 

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