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 Quality Improvement Stars Clinical RN is responsible for supporting quality performance improvement across Community Health Choice's Medicare Advantage and Medicaid lines of business.
This role focuses on improving Centers for Medicare and Medicaid Services (CMS) Part C Star Ratings. The Specialist drives data-informed initiatives, manages gap closure strategies, and supports cross-functional alignment to improve outcomes and compliance across all quality measures. JOB SPECIFICATIONS AND CORE COMPETENCIES Medicare Advantage Stars Performance (Medicare Part C): Track and support Stars performance across all Medicare Advantage quality domains (HEDIS, CAHPS, HOS, complaints, and appeals).
Monitor Star Ratings measure thresholds and cut points to identify underperforming areas. Collaborate with internal teams (analytics, care management, provider relations) to deploy targeted interventions. Assist in developing and disseminating member outreach materials.
Support member experience improvement activities (e.g., CAHPS training, call quality reviews). Provider Education and Support for D-SNP Stars Performance (Medicare Part C): Track and support provider specific Stars performance in collaboration with VBC and PR teams. Provide SME expertise for Stars improvement, including but not limited to educating on best practices for HEDIS, CAHPS, and HOS; how to operationalize gaps in care reports; and identification of areas of opportunity for performance improvement.
Assist in developing and disseminating provider educational materials and resources, including but not limited to provider toolkits, presentations, computer-based training, and office resources Cross-Functional Operations & Support: Maintain documentation for audits, state reporting, and CMS compliance. Assist in preparing dashboards, monthly performance summaries, and intervention tracking tools. Support annual measure updates, technical specification changes, and data integrity reviews.
Participate in quality committees and PIP (Performance Improvement Projects) as needed. Other Duties as Assigned
Education/Specialized Training/Licensure:Bachelor's degree in Public Health, Nursing, Healthcare Administration, or related field required. Registered Nurse, current license within the state of Texas. License must be active and in good standing required.
Master's degree in Public Health or Healthcare Management or related field preferred. Clinical Quality, Public Health or Healthcare, Certified Professional in Health Quality (CPHQ) preferred. Work Experience (Years and Area):3-5 years of experience in health plan quality improvement, Medicaid quality, or managed care, with 1 year of Quality Improvement experience.
Familiarity with state CMS D-SNP model of care requirements. Management Experience (Years and Area):N/A Software Proficiencies: Microsoft Office (Word, Excel, PowerPoint, Outlook) and Visio. Data visualization tools (e.g., Tableau, Power BI).
Other:Strong working knowledge of CMS Star Ratings, HEDIS, and CAHPS. Experience presenting data to providers and supporting practice transformation. Excellent communication, relationship management, and organizational skills.