The Quality Improvement Nurse will facilitate and work collaboratively with provider groups focused on Medicare Senior Products, and Medicaid plans to guide, recommend and develop practice specific strategies designed to improve all aspects of quality, cost and documentation.
Deliver provider/member-specific metrics around profit and loss and coach providers on gap closing opportunities for Humana members
Facilitate regular Provider Engagement Strategy team meetings with ability to prioritize and interpret data through the use of strong analytical skills
Successfully promote practice-patients’ participation in clinical programs - providing information on participation, Clinical Program availability/descriptions and facilitating members with program engagement
Accurately define gaps in Humana’s service relationship with providers and facilitate resolution
Review medical records and identify needed improvements that impact HEDIS measures or coding (i.e. identify deficiencies in data capture, use SQR to identify information and provide guidance to practice)
You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.
Is Accountable: You meet clearly stated expectations and take responsibility for achieving results.
Clinical Knowledge: You understand clinical program design, implementation, management/monitoring to support choice in consumer medical care. Understands the medical utilization implications of such programs
Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience
Strong interpersonal & relationship building skills
Experienced clinical background as RN
Strong analytic skills and ability to use data to drive improvement activities
Previous quality or process improvement experience in a hospital or physician office practice
Previous experience and/or knowledge of Quality Improvement or process improvement
Strong organizational and prioritization skills with ability to collaborate with multiple departments
Detail orientated and comfortable working with tight deadlines in a fast paced environment
Ability to work independently under general instructions, self-directed and motivated
Excellent PC skills (including MS Word, Excel and PowerPoint)
with reliable transportation
Knowledge of Provider Rewards and MRA Coding
Previous clinical or health plan operations experience
MSN/MBA/BSN or Bachelor’s degree in a related field.
Prior Medicare or Medicaid experience.
Knowledge of HEDIS/Stars/CMS/Quality
Clinical Innovations and Health Practitioners
Work Environment Type
Virtual/Work At Home
Yes, 75 % of the Time
Humana - 2 years ago
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Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...