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. Manager, Service Coordination will be responsible for the oversight of the infrastructure that coordinates necessary resources for members. Serves as a clinical leader and resource for Service Coordination.  The Sr. Manager, Service Coordination will analyze performance data, create reports for statistical and financial purposes, and recommend process improvements to enhance service delivery.  Responsible for updating the clinical model as needed in collaboration with executive leadership. Establishes strategic goals by gathering pertinent business, financial forecasting, and operational service.  Responsible for the implementation of policies and procedures, while adhering to regulatory and non-regulatory standards.

Develop new and update existing policies, procedures and job aids that relate to Service Coordination as needed to ensure compliance with HHSC, TDI, UMCC, and NCQA standards.
Responsible for completing operational and/or regulatory deliverables within established timelines.
Responsible for monitoring process workflows and proposing process improvements to better meet contractual and regulatory requirements.
Works directly with leadership, quality, and compliance departments to collect and analyze data, and respond to internal and external regulatory requests.
Responsible for creating and updating clinical models as indicated or required.
Responsible for maintaining compliance with federal and state regulations and contractual agreements to ensure that regulatory turnaround times and deadlines are met. Collaborate with leadership to develop and implement an audit monitoring tool to ensure compliance with state, federal, and NCQA requirements. Design and implement quality audits for clinical application of guidelines by reviewers and process improvement projects.

Oversight of Service Coordination staff, including but not limited to, daily management of productivity, documentation and compliance audits, timecards, coaching, counseling, and staffing coverage.
Continuous monitoring of documentation turnaround times and timely assessment completion to include outreach efforts in order to maintain compliance with state regulatory requirements.
Oversees recruitment, training, and ongoing staff development.  Partner with Human Resources to ensure state regulatory requirements are met.
Completes reviews of assessments to determine appropriateness of requested services, as well as reviews any potential reductions or denials of services.
Tracks, trends, and reports all data as it relates to Service Coordination programs to executive leadership.

Communicates all updates or changes in policies, whether verbal or written to the staff on a consistent basis to ensure consistency and accuracy in processes.
Perform in-person supervisory visits, including in-home visits as part of staff evaluation and monitoring.
Actively contributes to achievement of departmental goals, as identified in Department¿s annual business plan, including specific departmental process improvement plans and other duties as assigned.

Education/Specialized Training/Licensure: Unrestricted RN license in Texas required.
RUG Certified required

BSN, CCM Certification preferred

Work Experience (Years and Area): 10 years in healthcare, with at least 5 years¿ experience in STAR+PLUS, managed care, case management, or Medicaid waiver services.

Management Experience (Years and Area): 7 years¿ experience in management/ leadership role

Software Proficiencies: Microsoft Office (Word, Excel, Access, Outlook)

Strong leadership and communication skills, with the ability to motivate and develop high-performing teams.

Excellent problem-solving and decision-making abilities, with a customer-centric approach.

Ability to work effectively in a fast-paced, dynamic environment and adapt to changing priorities. 

Analytical skills with a focus on continuous improvement and operational excellence.

Job Family/Job Title Competencies
Problem Analysis
Attention to Detail
Analytical Thinking
Decision Making

Application Instructions

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