[Remote] Quality Improvement Professional at Humana

Illinois, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Bachelor's degree
2 years of experience related to process improvement, compliance measures, or auditing practices
OR 2 years of experience in Medicaid/Medicare Care Coordination
Ability to travel to Schaumburg office at minimum 2-4 times yearly for State and CMS Mock audits
Occasional travel to Louisville for an extended period during CMS Audits
Proven oral/written communication and presentation skills
Excellent analytical skills, able to manipulate and interpret data
Exceptional organizational and prioritization skills
Comprehensive knowledge of Microsoft Office Word, Excel, and PowerPoint
Ability to work within highly structured contractual time compliance requirements with occasional short turnaround time

Responsibilities

Implement quality improvement programs for all lines of business including annual program description, work plan, and annual evaluation
Perform quality investigations to implement and support quality improvement initiatives for the Illinois Long Term Service Support (LTSS) Program
Research best business practices within and outside the organization to establish benchmark data
Collect and analyze process data to initiate, develop, and recommend business practices and procedures that focus on enhanced safety, increased productivity, and reduced cost
Perform CMS and State audits focused on improving compliance and quality
Prepare cases, present cases and/or provide navigation responsibilities for CMS audits and State audits
Participate and present in reports for Quality Improvement Committee and other committees as needed
Collaborate with Managers, Senior Care Coordinators and Care Coordination staff for remediations identified on audits
Assist in special projects as needed
Development and review of internal quality metrics
Support process improvement initiatives
Assist in reviewing new Job Aids to support the team of Learning Design and Learning Facilitation staff
Review current Job Aids and Policies and Procedures as requested
Create and present education as requested by the Process Improvement Lead
Supports Operations Managers in quality improvement initiatives
Assist Managers in communicating audit findings to individuals and teams
Participates in Interrater Reliability (IRR) meetings and assists in the development of Interpretation Standards to guide audit scoring and increase consistency across the Process Improvement Team
Participates in root cause analysis research for audits
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed

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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