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 :

• Quality Improvement RN implements new and existing healthcare quality improvement initiatives and educational programs as required by Health and Human Services Commission (HHSC), Centers for Medicare and Medicaid Services (CMS), Texas Department of Insurance (TDI), or any other accrediting or regulatory bodies.
• Ensures maintenance of programs for members in accordance with prescribed quality standards as required by regulators and accrediting organizations.
• Reviews clinical data for clinical quality complaints; investigate and report on Abuse, Neglect, and Exploitation (ANE); conducts data collection, reporting and monitoring for key performance measurement activities.
• Provides direction and implementation of NCQA and URAC accreditation surveys and federal/state quality improvements/compliance activities.
• Contributes to the design of new or to refine existing initiatives to increase Provider/Member/Partners engagement and improve outcomes. 
• Coordinates cross functional efforts internally and externally as needed to support assigned projects.
• Supports the department with the collection and analysis of related data/information and in the development of strategies/processes to improve performance outcomes.

MINIMUM QUALIFICATIONS: 
Required:

• Education/Specialized Training/Licensure: Associate degree in nursing and RN License required. License must be active and in good standing.
• Work Experience (Years and Area): 3 years Managed Care experience required; with 1 year of Quality Improvement experience
• Software Proficiencies: Microsoft Office (Word, Excel, and Outlook) and Visio

Preferred:

• Bachelor’s degree in nursing preferred.
• Clinical Quality, Public Health or Healthcare, Certified Professional in Health Quality (CPHQ), Certified HEDIS Compliance Auditor(CHCA) preferred 

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!