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

Responsible for the oversight, active participation, and deliverables of risk adjustment projects/programs.  Assist with implementation of data analytics to assure accurate and complete quantitative analysis of Risk Adjustment data and presentation of analysis results.  Lead a cross-functional team to monitor performance and respond by adjusting strategy and processes where necessary.  Identifies and operationalizes programmatic initiatives required to achieve the organization¿s goals by working with external and internal partners.  Actively participate with committees/workgroups as assigned.


Essential Functions
Supervise Community Health Choice Risk Adjustment program (including RA Data Validation and RADV) for our Marketplace and Medicare membership. This program includes but is not limited to:
Supervise day-to-day activities of the risk adjustment team, including Nurse Auditors, Coders, and Specialists.
Supervise in the medical records abstraction and audit to ensure accurate CMS payment related to RADV program.
Assist with the database used for tracking, trending, and reporting seasonal suspecting projects, yearly EDGE server transmissions and yearly RADV audit.
Manage vendor relationships related to Risk Adjustment program.
Ensure compliance with HHSC, NCQA, CMS and/or any other body involved in policies or procedures of the department.
Supervise all other Risk Adjustment program-related activities and communication and work closely with the auditor to ensure effective program and positive outcome of the audit.
 Act as a subject matter expert for the organization at it relates to Risk Adjustment; including but not limited to implementation of new Risk Adjustment programs for other lines of business as needed.
Manage Data Validation Controls for the Risk Adjustment program in collaboration with both internal and external partners:
Supervise in the initiation/planning of data collection and data processing activities.
Assist in the coordination of data corrections for EGDE server enrollment and claims submission and reconciliation.
Responsible for monthly reporting and updates of the data/information activities.
Supervise all other Risk Adjustment Data Validation-related activities, communications, and ad hoc analyses.  
Other duties as assigned.

Education/Specialized Training/Licensure: Bachelor’s degree required in Business, Health Informatics, Public Health, Nursing, or related discipline required.
Risk Adjustment experience in coding and auditing preferred.
Work Experience (Years and Area): 5 years healthcare experience preferably in a managed care organization. Minimum of one (1) year performing risk adjustment performance measurement and/or project management in health care or health plan organization
Management Experience (Years and Area): N/A
2-5 years of management experience preferred.
Software Proficiencies: Microsoft Office (Word, Excel, Outlook)
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 required.
Knowledge of Risk Adjustment reporting and analysis.
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


Application Instructions

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