QI Stars Clinical RN

Community Health Choice is a non‑profit managed care organization serving over 400,000 members across Texas. Job Summary The Quality Improvement Stars Clinical RN supports quality performance improvement across Community Health Choice’s Medicare Advantage and Medicaid lines of business, focusing on 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 under‑performing 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 education 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, such as 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. Qualifications Education: Bachelor’s degree in public health, nursing, healthcare administration, or related field required. Master’s degree in public health, healthcare management, or related field preferred. Licensure: Registered Nurse, current Texas license in good standing required. Experience: 3–5 years in health plan quality improvement, Medicaid quality, or managed care. At least 1 year of Quality Improvement experience. Familiarity with state CMS D‑SNP model of care requirements. Proficiencies: Microsoft Office (Word, Excel, PowerPoint, Outlook) and Visio. Data visualization tools (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. #J-18808-Ljbffr