Humana Inc. is committed to putting health first and is seeking a Quality Improvement Professional to implement quality improvement programs for various lines of business. The role involves performing quality investigations, collaborating with teams for audit findings, and supporting process improvement initiatives.
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.
Performs CMS and State audits focused on improving compliance and quality.
Focus audits – may include annual and initial HRA compliance, Critical Incident audits, post discharge and transition of care contacts.
Provide Source System Validations for Universe and State reports
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.
Qualification
Required
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.
Preferred
Knowledge of HEDIS/Stars/CMS/Quality.
Experience in Medicaid or Medicare Guidelines.
Detail orientated and comfortable working with tight deadlines in a fast-paced environment
Benefits
Medical, dental and vision benefits
401(k) retirement savings plan
Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
Short-term and long-term disability
Life insurance
Humana is a health insurance provider for individuals, families, and businesses.
