[Remote] Manager, Quality Assurance (Medicaid) at Humana

Michigan, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Must reside in the state of Michigan
Active, unrestricted Registered Nurse (RN) license or active, unrestricted Licensed Social Worker (LBSW or LMSW) in the state of Michigan
Three (3) or more years of professional experience working with complex populations, home and community-based services, or in managed care settings
Two (2) or more years of management or supervisory experience
Proficiency in analyzing and interpreting data trends
Comprehensive knowledge of all Microsoft Office applications, including Outlook, Word, Excel, and PowerPoint
Exceptional oral and written communication and interpersonal skills
Ability to quickly build rapport
Experience with initiating service plans for members
Experience with disease management, health promotion, coaching, and wellness
Health Plan experience
Bilingual or Multilingual: English/Spanish, Arabic, Chaldean Neo-Aramaic, or other - Must be able to speak, read, and write in both languages without limitations or assistance

Responsibilities

Lead a team of Quality Assurance Professionals responsible for ensuring consistency of use and compliance to state and Humana requirements for Long-Term Services and Supports (LTSS) eligibility determination and service authorization
Collaborate with external partners such as Area Agencies on Aging (AAA) and monitor day-to-day operational activities with AAAs
Oversee the External Oversight Team (Quality Assurance professionals and Care Management Support Assistants) staff and monitor compliance with Home and Community-Based Services (HCBS) eligibility determination, service authorization, and other key LTSS compliance or operational metrics
Develop policies and procedures to ensure compliance with state and federal requirements and incorporate industry best practices
Provide real-time training/re-training to downstream entities on ongoing compliance requirements, policies, and procedures
Support leadership in meeting goals of the department/market
Participate in Interdisciplinary team meetings
Conduct briefings, area meetings, and maintain frequent contact with internal and external stakeholders such as other Humana departments
Liaise and maintain frequent contact with external stakeholders and vendors such as Area Agencies on Aging, conducts briefings and area meetings

Skills

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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