[Remote] Quality Compliance Professional at Humana

Kentucky, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

3+ years of previous experience working with member outreach on quality and performance improvement activities
2+ years previous experience in healthcare quality improvement/quality operations
Knowledge of HEDIS/CMS/Quality
Experience with healthcare quality measures (example HEDIS, CAHPS)
Comprehensive knowledge of Microsoft Office (Word, PowerPoint, Excel with intermediate skills in pivot tables/filtering, charts, formulas)
Bachelor’s degree
Quality improvement experience with the Medicaid population
Certified Professional in Healthcare Quality (CPHQ)
Previous quality or process improvement experience in a hospital or physician office practice
Ability to work independently under general instructions, self-directed and motivated

Responsibilities

Participate in performance and quality improvement projects by implementing member and provider targeted interventions to improve health outcomes and member and provider experiences
Implement member outreach calls
Conduct medical record audits to evaluate provider compliance with clinical practice guidelines, best practices, and regulations in collaboration with internal and external stakeholders
Conduct provider outreach to close care gaps, audit records to identify improvement opportunities, and abstract data from records to close gaps
Update quality documents (example: quality improvement program description, work plans, and evaluation)
Attend Quality Improvement Committee meetings
Complete and update reports (including State Reports and Kentucky Medicaid Quality Improvement Committee reports)
Participate in multidisciplinary committees, both internal and external
Build strong relationships with internal and external stakeholders
Utilize excellent written and oral communication 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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