Job Description

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job—it’s a passion to serve and improve lives every day.

Primary Purpose

Parkland Community Health Plan’s (PCHP’s) Clinical Quality Investigator supports quality-related investigations, quality of care concerns, and as needed, member complaints.

Minimum Specifications

Education

• Bachelor’s degree in nursing required.
• Master and/or other advanced degree in healthcare related field preferred.

OR

• If serving behavioral health population, bachelor's degree in nursing or master’s degree in social work, or a related field required.

Experience

• Two (2) years of experience in healthcare, managed care investigations or quality/process improvement.
• Clinical experience in the field of obtained license is preferred.
• Experience with managed care plan and/or Medicaid experience including NCQA, URAC, CMS, or HHSC is preferred.

Certification/Registration/Licensure

• Must have current RN license or valid temporary permit with the Texas Board of Nursing or valid Compact RN license required.

OR

• If serving behavioral health population, current RN, LCSW, LMFT, or LPC in the state of Texas is required

Skills or Special Abilities

• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.
• Excellent analytical and problem-solving skills.
• Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Ability to write clearly and succinctly with a high level of attention to detail.
• Ability to work independently and as part of a team collaborating with other departments and organizations.
• Skilled at providing feedback and offering corrective actions when necessary.
• Strong ability to handle and resolve escalated issues related to medical record audits and quality improvement projects.
• Proficient computer and Microsoft Office skills. Ability to learn new software programs.
• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Responsibilities

Operations

• Oversees and reviews clinical charts for the following: sentinel events, quality of care concerns, and reportable incidents, patient safety, and substandard care.
• Works with providers, internal teams, and regulatory agencies to implement quality improvement actions.
• Resolves QOC complaints within required time frames complying with Medicaid managed care regulations.

Reporting and Investigation

• Supports the tracking and monitoring of clinical investigations.
• Ensures PCHP’s accountability for compliance by overseeing, following up and resolving investigations in partnership with Healthcare Services and complying with state and federal regulations.
• Conducts investigations into quality-of-care complaints related to providers and member grievances,
• Identifies opportunities for improvement through the investigation process and provide recommendations for process enhancement in order to augment investigative outcomes and performance.
• Accurately tracks, reports, and follows up on credentialing and peer review concerns.
• Leads required regulatory investigation process and reporting to ensure proper and timely notification of case activity to the appropriate regulatory and/or law enforcement agency.
• Prioritizes reports according to business needs, regulatory requirements, urgency, and other key business factors.
• Tracks and follows all investigation data in addition to robust analysis of trends and patterns.
• Prepares summary of findings and recommends next steps.
• Prepare reports for Quality Committees, regulatory agencies, and leadership.

Quality

• Integrate health literacy principles into all communication including Members and Providers.
• Support strategies that meet clinical, quality and network improvement goals.
• Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
• For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.

Regulatory

• Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

Professional Accountability

• Promotes and supports a culturally welcoming and inclusive work environment.
• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements.
• Attends required meetings and town halls.
• Recognizes and communicates ethical and legal concerns through the established channels of communication.
• Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Maintains confidentiality at all times.
• Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. 

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