[Remote] Senior Stars Improvement, Clinical Professional BSN/RN at Humana

Florida, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

FL RN License
Must reside in the state of Florida
Two years of prior HEDIS, STARS and/or quality improvement experience in Medicaid or Medicare (Medicaid quality improvement a plus)
Proficient/ intermediate utilization of Excel and PowerPoint
Prior experience in a fast-paced insurance or health care setting
Proven analytical skills
Excellent communication skills, both oral and written
Strong relationship building skills
Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Responsibilities

Responsible for the development, implementation and management oversight of the company's Medicare/Medicaid Stars Program
Responsible for a provider assignment of 50+ Medicaid provider groups
Oversee HEDIS, quality & performance improvement and required quality activities that are related to NCQA health plan performance rating as well as the Agency’s Quality Withhold and Liquidated Damages programs for assigned providers
Supports improvement strategies through engagement with internal and external stakeholders
Monitors assigned value-based and non-value-based provider/provider groups’ performance in key performance indicators related to preventive care, care of chronic conditions and identified medical metrics (ex. HEDIS, APT, readmissions, ED utilization, polypharmacy, etc.)
Actively engages provider during virtual visit to facilitate education, HEDIS outcomes, care of members and bi-directional feedback
Attends JOCs with providers and participates in active discussions on HEDIS, member care, and clinical/quality outcomes
Communicate clinical quality initiatives to assigned providers
Educate and assist providers in reducing potential preventable events
Educate providers and staff about Medicaid Consume Assessment of Healthcare Providers and Systems (CAHPS) survey
Support improvement in member experience through education, information and resources related to the annual Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and Humana’s Member Experience Medicaid Survey (MEMS)
Continue to focus efforts and identify opportunities on performance improvement for assigned providers

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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