JOB SUMMARY
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.

JOB SPECIFICATIONS AND CORE COMPETENCIES
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.

QUALIFICATIONS:
Education/Specialized Training/Licensure: Bachelor's 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 monitoring, workflow automation, and research tools preferred.

Other: Strong verbal and written skills required.

Proficient Computer Literacy with the ability to use Network Search Engines



Job Family/Job Title Competencies
Problem Analysis
Attention to Detail
Analytical Thinking
Results Oriented

List any additional competencies not indicated above:
Good Verbal Skills Set
Good Writing /Composing

INTERPERSONAL SKILLS
Communicate effectively with individuals from varied experiences, perspectives and backgrounds, deal with individuals in a tactful, congenial, personal manner.
Interact successfully in a team environment.
Effectively communicate in a tactful, congenial, and professional manner
Receptive to feedback and change
Communicate effectively across various functional areas.


Physical Requirements:
Ability to work autonomously in a fast-paced environment with multiple projects and deadlines.
Ability to prioritize amongst competing priorities.