POSITION SUMMARY/RESPONSIBILITIES
Serves as a Provider Performance Improvement Nurse in the Quality Management Division. Serves as a team member for provider performance improvement efforts related to Healthcare Effectiveness Data and Information Set (HEDIS) outcomes, Pay for Quality (P4Q) outcomes, Strategic Initiatives, and other provider incentivized clinical and non-clinical outcomes. Identifies and monitors ongoing issues and areas of opportunities based on clinical documentation reviews, by providing remediation, education, feedback and process improvement for providers, provider clinic staff, and internal staff, related to clinical care and clinical outcomes of clinical programs. Develops education content based on Clinical Practice Guidelines, Best Practices, program requirements, and other organization goals. Represents the department in practices of in-person, digital, and telephonic education on content matters.
EDUCATION/EXPERIENCE
Managed care experience is preferred. Knowledge of coding resources (DRG, ICD and CPT) is preferred. Knowledge of Medicaid and Medicare, community resources, alternate funding programs, Texas Health and Human Services Commission (HHSC), Texas Department of Insurance (TDI) standards, and National Committee for Quality Assurance (NCQA) in a managed care setting is preferred. The ability to manage multiple projects simultaneously are required. Experience in clinical education development and presentation is preferred. Information Technology systems and applications and other job-specific applications are required. Recent experience with electronic learning development, curriculum design, training methodologies, and process improvement is preferred.
LICENSURE/CERTIFICATION
Must be licensed as a Registered Nurse in the State of Texas.
