Nurse Auditor (RN) - Community Health Choice
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.
Skills / Requirements
Actively participate in the Risk Adjustment and HEDIS projects for the organization as a nurse auditor. Assist team with data analytics to assure accurate and complete quantitative analysis of HEDIS and Risk Adjustment data. Be familiar with and act as a resource for the organization regarding NCQA HEDIS and CMS QHP Measures Technical specifications; along with Risk Adjustment, including RADV. Collaborates with teams regarding workflow process improvement, document management, and abstraction education as it relates to HEDIS/Risk Adjustment projects. Responsibilities include monitoring, tracking, trending, analyzing, and reporting all data, performance measures, and other required information requested by the 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. Monitors data and action plans as they relate to projects/programs overseen by the Risk Adjustment/HEDIS team.
1. Education/Specialized Training/Licensure: Registered Nurse in the state of Texas, BSN preferred
2. Work Experience: Two years of experience working in a managed care environment with a strong working knowledge of ICD -10 coding. Experience in Marketplace or Medicare Advantage Plan to include experience in Risk Adjustment preferred.
3. Software Operated: Microsoft Office (Word, Excel, Outlook)
1. Communication Skills:
Above Average Verbal (Heavy Public Contact),
Exceptional Verbal (e.g., Public Speaking)
Writing /Composing: (Correspondence / Reports
2. Other Skills: Analytical, Medical Terminology, Statistical, MS Word, MS Excel
3. Advanced Education: Bachelor's Degree Major: BSN preferred
4. Work Schedule: Flexible
5. Other Requirements:
Data analysis skills/ critical thinking skills
Knowledge of State Medicaid, Marketplace and/or Medicare
Knowledge of HEDIS and/or Risk Adjustment a plus