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

Childrens 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.

JOB SUMMARY

Responsible for performing telephonic or face-to-face clinical assessments for the identification, evaluation, coordination, and management of member's needs, including physical health, behavioral health, social services and long-term services and supports.

Identifies members for high-risk complications and coordinates care in conjunction with the member and the health care team.

Manages members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits.

Obtains a thorough and accurate member history to develop an individual care plan.

Establishes short- and long-term goals in collaboration with the member, caregivers, family, natural supports, physicians; identifies members that would benefit from an alternative level of care or other waiver programs.

The RN has overall responsibility to develop the care plan for services for the member and ensures the member's access to those services.

May assist with the implementation of member care plans by facilitating authorizations/referrals for utilization of services, as appropriate, within benefits structure or through extra-contractual arrangements, as permissible.

Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on the development of care management treatment plans.

May also assist in problem solving with providers, claims or service issues.

Directs and/or supervises the work of any LPN/LVN, LSW, LCSW, LMSW, and other licensed professionals other than an RN, in coordinating services for the member by, for example, assigning appropriate tasks to the non-RN clinicians, verifying and interpreting member information obtained by these individuals, conducting additional assessments, as necessary, to develop, monitor, evaluate, and revise the member's care plan to meet the member's needs, and reviewing and providing input on the non-RN clinicians' performance on a regular basis.

Assists in meeting member needs by referring members to internal and external resources.

Provide follow up with internal and external resources, providers, and state programs.

Coordinate with and participate in ICT meetings with Nursing Facility Staff, member, Responsible Party, treating physicians, therapists, and any other applicable parties.

Coordinate and assist with the transition to the community through the Money Follows the Person (MFP) process for any member who indicates a desire to leave the nursing facility.

Marginal Functions

Provide input and/or data to direct supervisor/manager related to any internal or external mandatory audit or reporting.

Serve as mentor, subject matter expert or preceptor to new staff.

Involved in process improvement initiatives.

Assist in problem solving with providers, claims or service issues.

Community Health Choice's Core Competencies

Customer Focus
Reliability and Dependability
Honest and Integrity
Change Management
Teamwork
Impact/Influence + Strategic Vision

People/Team Development

Other duties as assigned.


MINIMUM QUALIFICATIONS:
Education/Specialized Training/Licensure: Requires a current unrestricted RN license in Texas, Graduate of an accredited school of nursing.

Bachelors degree in nursing preferred.

CCM

Work Experience (Years and Area): 3-4 years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role; or any combination of education and experience, which would provide an equivalent background.

1 year experience working with population who receive waiver services,1 year experience working with persons with disabilities/chronic conditions and Long-Term Services & Supports.

Management Experience (Years and Area): N/A

Software Proficiencies: Microsoft Office, Clinical documentation platforms, Internet

Other: Local travel required.

Reliable transportation with valid driver's license with good driving record