Sr. Manager, Risk Adjustment & HEDIS - 152171
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.
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.
The Sr. Manager, Risk Adjustment & HEDIS is responsible for the oversight, active participation and deliverables of Marketplace Risk Adjustment projects/programs, including EDGE submission, HCC coding and RADV audit. Responsible for the oversight, active participation and deliverables of Marketplace, Medicaid and Medicare Advantage-related HEDIS requirements and analysis, including system submission, ROADMAP and measurement collection, validation and reporting. Responsible for oversight, active participation and deliverables of Marketplace, Medicaid and Medicare Advantage data analytics related to HEDIS and Risk Adjustment to assure accurate and complete quantitative analysis and presentation of analysis results. Additonal responsibilities include:
- direct supervision of staff management of both HEDIS and Risk Adjustment programs, including Nurse Auditors, specialists, analytic and clinical staff.
- Building and leading cross-functional teams to monitor performance and respond by adjusting strategy and processes where necessary.
- Identifying programmatic initiatives required to achieve the organization's goals by working with external and internal partners.
- Bachelor's degree required in Business, Health Informatics, Public Health, Nursing, or related discipline
- Five years healthcare experience preferably in a managed care organization.
- Two years performing quality performance measurement/risk adjustment and/or project management in health care or health plan organization
- Two years management experience
- Analytical, Mathematics, Medical Terminology, Statistical
- Ability to manage complex projects across multiple departments, critical thinking skills
- Strong problem-solving, quantitative and analytical skills
- Ability to use business intelligence query tools, computer spreadsheet (Excel), and database (Access and others, including Visual Basic) at advanced level
- Working knowledge of Structured Query Language (SQL) and Extensible Markup Language (XML) Knowledge of Risk Adjustment reporting and analysis.
- Knowledge of Quality Measurement reporting and analysis.
- Proven skills in report writing and report development. Dashboard development skills a plus.
- Proven skills with data presentation including charts, graphs and other exhibits.
- Ability to communicate effectively both orally and in writing
- Ability to handle multiple responsibilities and changing priorities
- Ability to quickly learn and implement knowledge of new technical processes
- Must pay attention to details
- Excellent organizational skills
Benefits and EEOC
Community employees’ benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.
Community is an Equal Opportunity Employer.