Sr Clinical Adherence Analyst

About Us

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.

The Clinical Performance Adherence Specialist will monitor, analyze, and report the program outcomes for STAR, STAR+PLUS, Marketplace and DSNPs contracts. Responsibilities include auditing and monitoring the performance of staff to ensure the delivery of best practices, and to ensure state deliverables are timely. The Clinical Specialist will utilize training and auditing tools to monitor Service Coordination for all lines of business to ensure adherence to policy and procedures, regulatory requirements, and accreditation standards.

Responsible for monitoring and reporting the activities of Medical Affairs:
Service Coordination, Case Management and Utilization Management programs, to ensure all clinical documentation and operational activities to include quality metrics, contractual regulatory, assessment, and operational reporting requirements are met for STAR, STAR+ Plus, DSNP and Marketplace

The Clinical Performance Adherence Specialist will perform investigation of performance inefficiencies and deficits, analyze data for trends, identify process gaps, and report all potential risks and root causes. The Clinical Performance Adherence Specialist will develop and draft proposals to mitigate process gaps to leadership.

Collaborates with internal and external stakeholders to respond to regulatory agency requests (i.e., HHSC) for monthly and annual reporting. Analyze, track, trend, and report on metrics developed within the Model of Care for all lines of business.

Develop and utilize approved auditing tools while conducting monthly audits on Medical Affairs staff and clinical documentation. Responsible for meeting required performance and quality metrics and ensure reviews, deliverables, and reports are completed within established regulatory, and state requirements.

Provides reports and feedback to management regarding performance of Medical Affairs staff regarding adherence to policies and procedures, regulations, and standards.

Proactively identify risks and mitigation activities thus ensuring contract requirements are met. Identify opportunities for improvement, via root-cause analysis, while utilizing a process improvement cycle to recommend solutions for identified problems.

Develop and/or revise training materials when systematic deficiencies are identified. Draft and recommend updates to policies and procedures to reflect changes to regulatory and accreditation standards, while monitoring regulatory requirements on an ongoing basis.

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.

Education/Specialized Training/Licensure:
Bachelor9s degree or higher in Nursing, Social Work, Clinical Informatics, or related Health Sciences required

Licensed Clinician such as:
Registered Nurse, Licensed Social Worker, Licensed Vocational Nurse, or a Masters Degree or Higher in Business, Population Health, or Healthcare preferred.

Work Experience (Years and Area): 5 years in healthcare setting, including 2 years in managed care organization required.

Auditing, Compliance, And/or Analytics Experience Preferred.

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

Proficiency in business…