[Remote] Quality Audit Professional at Humana

Kentucky, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

U.S. citizenship
Interim approval for government security clearance (NBIS)
Active licensed RN in state of employment
3 years clinical RN experience
2 years of Utilization Review, Case Management, or Quality Management experience
Strong analytical skills, experience manipulating and interpreting data
Ability to work 7 - 4 p.m. E.T. or 8 - 5 p.m. E.T
Minimum download speed of 25 Mbps and upload speed of 10 Mbps internet connection

Responsibilities

Analyze and investigate quality issues
Support the Healthcare Quality Management Team in administering and implementing the Clinical Quality Management Program (CQMP)
Collect and review records, summarize issues, and work with Medical Director as needed
Implement corrective actions as assigned
Coordinate case presentations and present to Patient Safety Peer Review Committee
Audit quality cases for compliance
Participate in department projects as available
Review medical records, create case summaries, and present potential quality issue (PQI) cases to Medical Director
Provide assistance to Medical Directors to ensure corrective action plans (CAPs) are developed & implemented
Monitor CAP for timeliness, and enter data into the Provider Trending Database
Monitor cases entered in the Clinical Quality Management Database (CQMD) for accuracy, timeliness of completion, and documentation
Review PQI's from all sources to determine the need for medical record review
Participate in focused reviews as available

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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