JOB SUMMARY

The overall objective of the Performance Adherence Specialist is to monitor and report the program outcomes for the STAR, STAR+PLUS, Marketplace and DSNPs contracts. The Performance Adherence Specialist will be responsible to monitor and report 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 Specialist is responsible for auditing and monitoring the performance of staff to ensure the delivery of best practices, and to ensure state deliverables are timely. The 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.

JOB SPECIFICATIONS

• Monitors Medical Affairs performance for all lines of business for adherence to policies and procedures, regulatory requirements, and accreditation standards.
• Collaborates with internal and external stakeholders to respond to regulatory agency requests (ie. HHSC) for monthly and annual reporting.
• Track and report on metrics developed within the Model of Care for all lines of business.
• Utilizes approved auditing tools and conducts monthly audits on all Medical Affairs staff.
• Provides reports and feedback to management regarding performance of Medical Affairs staff regarding adherence to policies and procedures, regulations and standards.
• Identifies opportunities for improvement and uses a process improvement cycle to recommend solutions for identified problems.
• Proactively identify risks and mitigation activities thus ensuring contract requirements are met.
• Monitors regulatory requirements on an ongoing basis.
• Recommends modifications to training materials when systematic deficiencies are identified.
• Recommends updates to policies and procedures to reflect changes to regulatory and accreditation standards.

QUALIFICATIONS:

• Education/Specialized Training/Licensure: High School diploma required.
• Associate degree or higher preferred.
• Work Experience (Years and Area): 5 years health care setting, including managed care organization.
• Auditing/compliance experience preferred.
• Software Proficiencies: PC Microsoft Office (Word, Excel, Outlook)