RN-STAR+PLUS Service Coordinator Manager
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
The Service Coordinator Manager will be responsible for the oversight of the daily operations and coordination related to the activities assigned to Service Coordination staff including daily team operations, internal and external departmental relations, and recruitment/evaluation of staff. The Service Coordinator Manager oversee the infrastructure that coordinates necessary resources for members. The candidate compiles and reviews multiple reports on work function activities for statistical purposes, financial tracking purposes and for process improvement to identify trends, assist in financial forecasting, and make recommendations to leadership. The Service Coordinator Manager will develop and implement appropriate policies and procedures; ensure staff are able to facilitate member and provider needs through entire case management cycle.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Oversight of Service Coordination staff, including but not limited to, monitoring process workflows, and proposing process improvements to better meet contractual and regulatory requirements.
Works directly with leadership, quality, and compliance departments to collect and analyze data, and respond to internal and external regulatory requests.
Continuous monitoring of documentation turnaround times and timely assessment completion to include outreach efforts in order to maintain compliance with state regulatory requirements.
Oversees recruitment, training, and ongoing training of Service Coordination staff with the Human Resources and Training departments in accordance with state regulatory requirements.
Assists leadership in reviewing and updating clinical model as indicated or required.
Communicates all updates or changes in policies, whether verbal or written to the staff on a consistent basis to ensure consistency and accuracy in processes.
Oversees daily management of Service Coordination staff including timecards, counseling, coverage, productivity etc.
Collaborate with leadership to develop and implement an audit monitoring tool to ensure compliance with state, federal, and NCQA requirements.
Completes documentation and compliance audits of assigned staff.
Completes reviews of assessments to determine appropriateness of requested services, as well as reviews any potential reductions or denials of services.
Acts as a resource for assigned staff.
Ensures that regulatory turnaround times and deadlines are met.
Tracks, trends and reports all data as it relates to Service Coordination programs.
Responsible for completing operational and/or regulatory deliverables within established timelines.
Develop new and update existing policies, procedures and job aids that relate to Service.
Coordination as needed to ensure compliance with HHSC, TDI, UMCC, and NCQA standards.
Perform in-person supervisory visits, including in-home visits as part of staff evaluation and monitoring.
Maintain compliance with federal and state regulations and contractual agreements
Identify and develop specific programs and create educational training for staff.
Design and implement quality audits for clinical application of guidelines by reviewers and process improvement projects.
Community Health Choice's Core Competencies
Reliability and Dependability
Honest and Integrity
Impact/Influence + Strategic Vision
Other duties as assigned.
Associate degree in Nursing required.
TX License in good standing; active and unrestricted required.
Bachelors or Masters Degree in Business, Healthcare, or related field preferred.
CCM Certification preferred.
RUG Certified preferred.
Work Experience (Years and Area):
7+ years in healthcare, with at least 2 years experience in Managed Care.
Analytical, Medical Terminology, MS Word, MS Excel.
Knowledge of Medicare and Medicaid.
10+ years of managed healthcare experience.
3+ years of experience working with STAR Plus members.
Experience with line management responsibility including clinical operations. Operational and process improvement experience.
Management Experience (Years and Area): 3-5 years of management or supervisory experience in a managed care setting required.
5+ years of management or supervisory experience in a managed care setting preferred.
STAR Plus supervisory or management experience preferred.
Personal Computer, Microsoft Office, Clinical Documentation Platforms required.
Altruista, Tableau, Power BI, ServiceNow, QNXT, Microsoft Teams preferred.
Local travel required
Reliable transportation with valid driver's license with good driving record required.