Medical Affairs Auditor - 153223

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

Childrens 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.

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 Medical Affairs Auditor collaborates with the departmental management team to assess, plan, develop and implement work product and process audits of clinical and nonclinical staff members contributing to Utilization Management, Care Management and Appeals related functions of the department. This position delivers reports and develops remediation plans to support staff learning and development as needed to ensure accurate and consistent use of clinical decision tools, appropriate clinical documentation and decision making. The auditor is responsible for clinical staff remediation activities on the appropriate use of policies, evidence-based guidelines, or other authorization criteria as adopted by the health plan and develops content for training material to support ongoing staff education delivered in collaboration with training staff from Learning and Development.

QUALIFICATIONS:

• Bachelor's Degree in Nursing with active Texas nursing license required.
• One of the following preferred: Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.
• Three years' experience in Utilization Management (UM) in a managed care health plan and two years' experience as a trainer/auditor are preferred.
• Medicaid, Health Insurance Marketplace and Medicare Population experience preferred.

OTHER SKILLS:

• Microsoft Office (Word, Excel, Outlook)
• Above Average Verbal (Heavy Public Contact)
• Exceptional Verbal (e.g., Public Speaking)
• Bilingual (English/Spanish) preferred
• Writing /Composing:/Correspondence/Reports
• Analytical, Medical Terminology, Research, Statistical

Community employees benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.

Community is an Equal Opportunity Employer.