Care Mgmt. Team Lead Nurse RN

About Us

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, including CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid
• Health Insurance Marketplace Plans offering 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, combining 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 ensure 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 and offers 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 Harris County taxpayers.

About the Role

The Care Management Team Lead Nurse RN will manage Community Health Choice (CHC) members with chronic diseases, conditions, or medically complicated needs through comprehensive evaluation and coordination of resources. The Care Manager Team Leader will participate as a team member in the CHC Care Management program, collaborating with utilization management, member services, and quality improvement departments.

Responsibilities

• Manage an abbreviated caseload to maintain expert knowledge in care management processes
• Identify and contact potential members for Care Management Programs within program time frames
• Participate in member events, baby showers, and health fairs in collaboration with CHC outreach staff
• Perform assessments of identified members for Care Management Services within program time frames
• Complete Risk Stratification on enrolled members in Care Management Programs within program time frames
• Contact providers of enrolled members within Care Management program specifications
• Develop Care Management action plans for members in collaboration with members and providers within program time frames
• Input authorizations for Home Health Agencies and DME companies to facilitate member/provider requests for supplies and services
• Monitor events and outcomes of members within the Care Management Program in relation to action plans
• Record Care Management activities and contacts within the Care Management Module routinely and timely
• Coordinate daily operational aspects of the team and assist the manager with staff supervision
• Monitor and facilitate equal distribution of workload assignments
• Assist the manager in setting productivity goals and monitor staff performance and productivity
• Review and document staff productivity monthly and on an ad hoc basis
• Inform the manager about escalated issues and collaborate on resolutions
• Monitor adherence to attendance, PTO, lunch, and break guidelines
• Provide information for employee performance reviews
• Ensure staff completes required trainings
• Hold monthly team meetings with staff and document minutes
• Conduct evaluations of team members and implement improvement plans as necessary
• Complete documentation and call monitoring audits quarterly and on an ad hoc basis
• Identify training needs and assist with new and ongoing employee training, including development of training documents
• Identify opportunities for process and productivity improvement and share with the manager
• Coach and mentor staff on identified issues
• Assist with the development and/or redesign of the Care Management Program
• Recommend improvements to the Care Management Program
• Maintain and report required Program Analytic requirements
• Develop program-related member outreach and educational activities
• Actively contribute to the achievement of departmental goals as identified in the Department's annual business plan, including specific process improvement plans
• Perform other duties as assigned

Requirements

• Associate Degree required; Bachelor's Degree preferred
• Current Texas RN license required
• Certification in Clinical Case Management (CCM) required
• 3 years of clinical experience plus 1 year of Managed Care experience
• 1 year of case management experience

Skills

• Proficiency in Microsoft Office (Word, Excel, Outlook)