Compliance Specialist

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.

Job Summary

The Compliance Specialists operate under the supervision of the Compliance Director or Compliance Manager, playing a crucial role in reporting and special projects. This role is responsible for providing essential information, detailed analysis, and practical recommendations to ensure Community adheres to all regulatory, legal, and contractual requirements. In addition to these key responsibilities, the Compliance Specialist conducts thorough research and collaborates with operational teams to devise effective compliance solutions. They also perform internal and external monitoring activities as part of the Compliance program, following the guidelines outlined in the annual audit and monitoring work plan.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Internal and External Monitoring

Independently assesses regulatory correspondence for proper prioritization and resolution. Supports the assessment of regulatory correspondence to help prioritize and resolve issues. Communicates with regulatory contacts when needed and takes part in committee meetings to provide updates to the business. Capable of assisting in preparing presentations. Maintains trackers for all MCO and Federal notices and ensures all actions are tracked through completion. This includes proper risk leveling, identification of action, disseminating to the correct internal stakeholders and escalating issues to leadership. Must possess excellent written and verbal communication skills, attention to detail, as well as project management capabilities.

Internal and External Monitoring

Independently assesses regulatory correspondence for proper prioritization and resolution. Supports the assessment of regulatory correspondence to help prioritize and resolve issues. Communicates with regulatory contacts when needed and takes part in committee meetings to provide updates to the business. Capable of assisting in preparing presentations. Maintains trackers for all MCO and Federal notices and ensures all actions are tracked through completion. This includes proper risk leveling, identification of action, disseminating to the correct internal stakeholders and escalating issues to leadership. Must possess excellent written and verbal communication skills, attention to detail, as well as project management capabilities.

Regulatory Analysis and Reporting

Supports senior compliance specialist in submitting reports and adhering to deadlines. Maintains access to report portals and ensures a thorough understanding of the upload processes. Assists in coordinating efforts to facilitate timely submissions while helping to address any issues that may arise during the reporting process.

Readiness/Operational Review Contact Support

Assists leadership in meeting deliverable deadlines by facilitating the upload and distribution of necessary materials. Keeps leadership organized and on track for all due dates related to readiness and operational reviews. Provides proactive reminders and support to ensure timely completion of tasks and adherence to established timelines.

Research and Development

Conducts thorough research on compliance-related topics, industry trends, and best practices to inform policy development and enhance organizational compliance strategies. This research aids in identifying potential compliance risks and supports the formulation of effective solutions.

Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans and other duties as assigned.

Reports to Position Title: Compliance Director/Manager

Qualifications

Education/Specialized Training/Licensure: BA/BS in Healthcare Administration, Business Administration, or related field required.

2 years of experience in project management and regulatory experience activities required.

Master's Degree preferred

Work Experience (Years and Area): Minimum 2 years in the healthcare payor industry (Medicare/Medicaid) or similar field required.

Software Proficiencies: Microsoft Office (Word, Excel, PowerPoint, MS Teams, MS SharePoint, Outlook)

Other: Understanding of Texas health insurance market and regulators such as TDI, HHSC, and CMS.