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 overall objective of the Performance Adherence Manager is to partner with Quality to 
provide an ongoing and defined quality improvement and oversight program by which 
Community and its internal and external stakeholders can utilize objective measures, to 
monitor and evaluate the program outcomes for the STAR, STAR+PLUS, Marketplace and 
DSNPs contracts. 
The Performance Adherence Manager will be responsible to assess, design, update, monitor 
and improve the activities of Service Coordination, Case Management and Utilization 
Management programs, to ensure all operational activities to include quality metrics, 
contractual regulatory and operational reporting requirements are met for STAR, STAR+ Plus, 
DSNP and Marketplace.
The Performance Adherence Manager is responsible for implementation of an interdepartmental 
auditing and monitoring framework to ensure the delivery of best practice, and to ensure state 
deliverables are timely. The Manager will develop training and auditing tools for service 
coordination for all lines of business to ensure adherence to regulatory requirements and 
accreditation standards. This position will assist the Director and Vice-President as the 
departmental liaison with the Compliance division for all issues / concerns and implementation of 
new regulatory requirements.

Reports to Position Title: Director
Employees Supervised Titles: Performance Adherence Specialist

Training/Licensure:Bachelors’ degree required preferably in a related field such as Nursing (BSN), Business Administration or Healthcare Administration
Work Experience (Years and Area):

  • 5 years health care setting, including managed care organization. 
  • Auditing/compliance experience preferred.

Management Experience (Years and Area):

  • 3 years of supervisory / management experience in Managed Care is preferred

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

Application Instructions

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