QI Stars Clinical RN

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, including 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 with 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 B benefits, Part D prescription drug coverage, and Medicaid benefits with additional health benefits such as dental, vision, and transportation Improving members’ experiences is at the heart of every Community position. We work to ensure that members have access to high‑quality health care they need and deserve. Community is accredited by URAC for its health plan operations and offers care management programs for asthma, diabetes, and high‑risk pregnancy. As an affiliate of the Harris Health System, Community is financially self‑sufficient and receives no financial support from Harris Health or Harris County taxpayers. Job Summary The Quality Improvement Stars Clinical RN supports quality performance improvement across Community Health Choice’s Medicare Advantage and Medicaid lines of business. The 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 aligns cross‑functional efforts 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 rating 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 educating on best practices for HEDIS, CAHPS, and HOS; operationalizing gaps in care reports; and identifying areas of opportunity for performance improvement Assist in developing and disseminating provider educational materials and resources, including 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 As needed to support the Quality Improvement program and organizational goals. Qualifications Bachelor’s degree in Public Health, Nursing, Healthcare Administration, or related field (required) Registered Nurse, current Texas license in good standing (required) Master’s degree in Public Health, Healthcare Management, or related field (preferred) Certified Professional in Health Quality (CPHQ) (preferred) 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 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 Software proficiencies: Microsoft Office (Word, Excel, PowerPoint, Outlook) and Visio; data visualization tools (e.g., Tableau, Power BI) #J-18808-Ljbffr Harris Health