HEDIS & Risk Adjustment Specialist
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 HEDIS & Risk Adjustment Specialist is responsible for implementing processes in the Performance Excellence department regarding project management, and quality improvement within a managed care organization. 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 Performance Excellence department. The current projects include but are not limited to HHSC Performance Improvement Projects, HHSC Frew, HHSC Pay for Quality, Delivery Services Reform Incentive Payment (DSRIP) Program, Network Access Improvement Program (NAIP), Quality Rating System (QRS) Quality Improvement Strategy, Member Complaints, Health Plan Accreditation, Member Satisfaction Surveys, and Provider Satisfaction Surveys. Contributes to the design of new or to refine existing initiatives to increase Provider/Member/Partners engagement and improve outcomes. Coordinates cross functional efforts internally and externally as needed to support assigned projects. Supports the department with the collection and analysis of related data/information and in the development of strategies/processes to improve performance outcomes.
- Bachelor's Degree in Business (BA), Social Work, Health Care, Project Management or related field required.
- Master's degree preferred.
- Three years of managed care, health care, or related experience; with a minimum of one year being in Quality Improvement or Project Management
- Data analysis skills
- Knowledge of State Medicaid programs a plus
- Excellent writing skills
- Analytical/Critical Thinking Skills
- Mathematical/Statistical Analysis Skills