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

JOB SUMMARY 

The HEDIS Data Specialist will be responsible for analyzing and interpreting healthcare data, with a specific focus on quality improvement and HEDIS metrics. The primary goal is to ensure compliance with HEDIS standards and identify opportunities for improving reporting, healthcare quality and performance. 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), The National Committee for Quality Assurance (NCQA), or any other accrediting or regulatory bodies and supporting the Quality/HEDIS department with the collection and analysis of related data/information and in the development of strategies/processes to improve performance outcomes

JOB SPECIFICATIONS 

Responsible for Data Analysis and Validation, including communicating with internal and external stakeholders to gather business requirements, participate in the initiation and planning of data collection and data processing activities, including conducting and documenting data mapping.  
Assist in the monthly implementation of data submission, data/information validation, data/information analysis with vendors and other Community partners. Identify and assist with data corrections for HEDIS performance measures.
Create monthly scheduled reports and ad hoc reports related to business and audit needs. Review, analyze and evaluate data to determine trends, issues or opportunities for improvement and communicate with the appropriate department, including tracking the progress.

Collaborate with internal teams to ensure accuracy, timeliness and completeness of healthcare data received and transferred that impacts HEDIS or Quality metrics while interpreting HEDIS specifications and guidelines to ensure accurate measurement and reporting.

Assist with various aspects of the NCQA ROADMAP completion process and the HEDIS Audit, including issue log items and benchmarking.
Special Projects Responsible for completion of other duties and special projects as assigned.

Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plans. Other duties as assigned.

Reports to Position Title: Manager, HEDIS

QUALIFICATIONS: 
Education/Specialized Training/Licensure: Bachelor's degree in business (BA), Social Work, Health Care, Health Informatics, Project Management or related field required.

Masters degree preferred.

Work Experience (Years and Area): 3 years of managed care, health care, or related experience with a minimum of one year being in Quality Improvement or Project 
Management required.

Knowledge of State Medicaid and Exchange programs; HEDIS Experience preferred.

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

Power BI, SQL, SAS preferred.

Other: AHIMA/AAPC Certified Coder, Medical Billing and Coding Certification

Application Instructions

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