Job Abstract

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.

JOB SUMMARY

The Manager will supervise all Care Management (CM) functions for CHC and CHC members in the CM programs. The Manager will supervise CM staff in the enrollment and ongoing outreach to CHC members and care-coordination to members in the CM programs. The Manager will review all programs at least annually and work with Medical Affairs staff and senior leadership to update program goals and content. In addition, the Manager will identify other conditions for which CHC should prepare a care management program. The Manager will work with Analytics and Medical Affairs staff/management team to ensure that 1) members are being contacted and enrolled appropriately; program results, including ROI when measurable, are reported on a quarterly basis; program problems are identified; and 4) process improvements are recommended and implemented.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Oversees daily management of Care Management staff, including timecards,
• counseling, coverage, etc. Ensures that the regulatory turnaround times and deadlines are met.
• Ensures that monthly reports are reviewed with Director of Quality & Outcomes and Medical Affairs management team as needed monthly and implements appropriate corrective actions. Updates CM sections of the Key Management Report (KMR).
• Develop action plans to measure results and possible ROI for every program.
• Develop new and update existing policies, procedures and job aids that relate to Care Management programs as needed to ensure compliance with HHSC, TDI,
• UMCC, NCQA and URAC standards.
• Ensures that all CHC members identified as candidates for CM programs are processed and evaluated within the specified time frames. Monitor events and outcomes of members enrolled in Care Management.
• Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plans. Other duties as assigned.

QUALIFICATIONS:

• Education/Specialized Training/Licensure: Active Texas RN license required.
• BSN preferred. Certification in Clinical Case Management (CCM) preferred.
• Work Experience (Years and Area): 5 years experience in Care Management (Disease Management) or Care Management in an acute care setting or MCO. Other healthcare experience will be considered in lieu of CM experience.
• Management Experience (Years and Area): 3 years experience in management / leadership role.
• Software Proficiencies: Microsoft Office (Word, Excel, Access, Outlook)

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!