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 Manager Stars and Pay for Quality is responsible for informing, promoting, and leading the evolution of Community Health Choice to maximize quality as measured by the Centers for Medicare and Medicaid Services (CMS) STAR Rating System and Texas HHSC Pay for Quality program. The Manager Stars and Pay for Quality plays a pivotal role to strategically optimize operational initiatives plan wide to maximize Community's Duals Special Needs Plan (D-SNP) STAR ratings, and to maximize the Medicaid performance in the Pay for Quality program. Support the creation, drive implementation, and monitoring process of the program strategy, objectives, tactic, and initiatives to drive a year over year overall Star Ratings and meeting Program goals. This role focuses on assessing health plan performance, analyzing data to identify areas for improvement, developing actionable plans, and working cross-functionally with clinical and operational teams to improve health outcomes for members

JOB SPECIFICATIONS

Team expert, develop expert understanding of Star measures, ratings and methodology to inform strategic plan, drive the execution of work plan, initiatives, and overall Star and Pay for Quality performance. Lead and/or actively participate in provider meetings, workgroups, committees, etc. Lead assigned projects while maintaining all project management information including timelines, resources, issues, scope, and other related project activities. 
Attend partner meetings with quality performance updates, inform on initiatives, and provide recommendations.  Monitors key performance indicators (KPIs); intervenes as needed and escalate issues where performance falls outside of expected levels. 
Develop team and supervise Stars Clinical RN staff to partner with external providers to close care gaps and increase Star ratings.

Subject Matter Expertise liaison to stakeholders' enterprise-wide to provide strategic guidance to support and promote process deployment, refinement, and execution to maximize STAR ratings and P4Q performance. Ability to clearly communicate requirements and their impacts to operational systems enterprise-wide; collaboration with cross-functional teams to build an understanding of the intersection between STAR Rating and P4Q requirements and the operational excellence required to achieve exceptional member experience and outcomes. 
Stay informed and up to date about prospective changes to D-SNP STARS Program measures, reporting requirements and program updates, and communicate requirements to relevant stakeholders to maximize the time to adapt operational systems to changes in D-SNP STARS requirements.
Stay informed and up to date with prospective changes to the HHSC Pay for Quality and Medicaid MCO Report Card measures, reporting requirements and program update to be able to communicate with internal stakeholders the impact on Community's performance.

Collaborating with Community's teams, including but not limited to Population Health Management, Medical Management, Member Services, and Quality, to promote the evolution of operational systems aligned with STAR Rating Program goals and HHSC's Pay for Quality program goals. Collaborate with internal teams to ensure optimal Consumer Assessment of Healthcare Provider & Systems/Health Outcome Surveys (CAHPS/HOS) performance. 

Manage the day-to-day activities of the Stars Clinical RN staff positions. Collaborate with clinical QI RNs and other members of the Quality team.  Support development of an effective quality team across multiple functions.

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

Assist Director, Quality Improvement in facilitating the quality-related committees and sub-committees, providing expertise and guidance to cross-functional teams. Foster a culture of continuous improvement by promoting quality awareness and training across the organization.

Reports to Position Title: Director, Quality Improvement
Employees Supervised Titles: Stars Clinical RN staff

QUALIFICATIONS: 

Education/Specialized Training/Licensure: Bachelor's degree in clinical or health care field required.

Master's degree in a health care related field or business strongly preferred.

Work Experience (Years and Area): 5 years progressively responsible management experience in a health care environment. 

Minimum 3 years' experience if master's degree is held Medicare Advantage Stars program experience preferred

Management Experience (Years and Area): Minimum 3 years of experience in a leadership role including managing and overseeing quality staff, clinical staff, or manage quality initiatives. 

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

Application Instructions

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