Sr. Clinical Operations Analyst, 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
JOB SUMMARY: The Sr. Clinical Operations Analyst supports departmental clinical activities related to reviewing clinical information and claims data required for decision making by the Senior Leadership Team. This position works closely with the clinical operations team on initiatives to include working with leadership and analytics to respond and submit regulatory reporting requests.' Also working with IT and Medical Affairs Leadership to assist with system implementations and testing; and projects to monitor performance, validate outcomes, identify improvement opportunities that can be leveraged strategically, clinically and operationally. The analyst reviews aggregated clinical data for early issue detection, trend analysis and process analysis to identify improvement opportunities to ensure appropriate fiduciary control, cost containment and operational performance efficiency; collaborates with cross-functional departments in defining and selecting appropriate metrics, methods and tools, to evaluate key performance metrics in the determination of meeting contractual expectations and standards; and provides written documentation to management to support the development of clinical programs, processes and/or tools to ensure successful outcomes.
1. Education/Specialized Training/Licensure: Bachelor's or Master's Degree in Nursing,
One of the following preferred: Certified Case Manager, or Certified Managed Care Nurse or any other healthcare or management certification. Current unrestricted Texas RN license
2. Work Experience (Years and Area): 5 years of managed care, including 3 years¿ experience working within applicable state, federal, and third-party regulations required. Medicaid/Medicare population experience with increasing responsibility and 2 years of working with health-related data to analyze trends, identify utilization patterns and support decision making required.
3. Software Operated: Microsoft Office (Word, Excel, Outlook), InterQual
1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Exceptional Verbal (e.g., Public Speaking)
Languages: Bilingual (English/Spanish) preferred
Writing /Composing: Correspondence / Reports
2. Other Skills: Analytical, Medical Terminology, Research, Statistical
3. Advanced Education: Bachelor’s Degree Major: Nursing
Master’s Degree Major: Nursing, Business, Healthcare Administration or related field preferred.
4. Work Schedule: Flexible
5. Other Requirements: Previous experience in health care service setting;
Experience in utilization management/case management standards
Experience in clinical criteria reviews working with InterQual, TMPPM and other medical review guidelines required.
Familiarity with clinical and healthcare administrative data
Experience creating complex analyses and developing reports
Ability to rapidly learn new technology, concepts, models and methods and effectively employ in projects and processes
Interpersonal skills, excellent written and verbal communication
Ability to work effectively both independently and in cross functional teams
Broad business understanding of clinical development processes
Proven attention to detail and ability to think creatively and work collaboratively in a rapidly changing environment
POTENTIAL OCCUPATIONAL HEALTH EXPOSURES: Required to enter facilities where patient care is provided