The Senior Stars Improvement, Clinical Professional responsible for the development, implementation and management oversight of the company's Medicaid Stars Program. The Senior Stars Improvement, Clinical Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
The Clinical Provider Quality Improvement RN is what we refer to as the Senior Stars Improvement, Clinical Professional. This work focuses on areas of clinical emphasis. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
Review provider/member-specific UM and QI metrics and coach assigned providers/providers groups and/or MSO groups on gap closing opportunities and improve quality outcome through in-person/virtual/telephone/email and/or JOC meeting.
Provide resources and educational opportunities to providers and staff.
Promote practice-patients' participation in clinical programs - providing information on participation, Clinical Program availability/descriptions and facilitating members with program engagement.
Identify specific practice needs (e.g. use of most efficient interaction channel) to providing support.
Review medical records or claims to identify needed improvements that impact HEDIS measures or coding (i.e. identify deficiencies in data capture and provide guidance to practice).
Prepare quality slide and present quality/UM/CM slides at JOC meeting.
Educate providers and staff about Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
Unrestricted RN with license in the state of FL without any current disciplinary actions
3+ years of clinical experience
Strong knowledge of any and/or all of the following: HEDIS, STARS, Medicaid, Quality
Understanding of metrics, trends and the ability to identify gaps in care
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 written and oral communication skills
Excellent PC skills (including MS Word, Excel and PowerPoint)
Hours: 40-hour work schedule Monday-Friday, hours will be discussed with the leader.
Location: The work-style for this position is remote/work at home
Work at home: The business prefers candidates to reside within reasonable distance to Humana market office locations.
Counties Include: Orange, Osceola, Polk, Seminole and Brevard Counties, FL
Travel: Travel to physician offices 50% or more based on business needs. (See additional Information)
Work At Home Requirements:
Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work
Must have accessibility to hardwired high speed internet with minimum speeds of 10Mx1M for a home office (Wireless and Satellite are prohibited)
Bachelor's Degree in Business Administration, Health Administration or a related field
Progressive experience in the health solutions industry
Prior managed care experience
Proven organizational and prioritization skills and ability to collaborate with multiple departments a plus
Coding experience a plus
In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves. The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process.
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours