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)
Builds Trust: You honor your word by doing what you say you are going to do.
Drives for excellence: You are a continuous learner who encourages others to learn. By constantly upgrading your own work, you achieve results and outperform the competition.
Implementation/Execution: You are good at organizing and managing multiple priorities and/or projects by using appropriate methodologies and tools.
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.
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)
Travel 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
You will report to a Clinical Manager. This area is under the leadership of the SVP & Chief Operations Officer.
Clinical Innovations and Health Practitioners
Work Environment Type
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...