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The Quality Improvement Professional II will facilitate and work collaboratively with employed physicians (owned centers) and independent providers (IPA) in the Conviva network to provide support guidance, make recommendations and develop practice specific strategies designed to improve Medicare quality measures (HEDIS) as well as patient safety and patient experience (CAHPS-HOS).
You will monitor quality investigations and compliance procedures/processes. Manages quality management systems, department Sharepoint and departmental reporting. Audits processes as needed for compliance. Understands departmental segments organizational strategy and operating objectives including their linkages to related areas. Make decisions regarding own work methods, occasionally in ambiguous situations and requires minimal direction and receives guidance when needed.
Responsibilities:
- Quality Improvement Professional assigned to each market applies critical thinking to prioritize center/IPA outreach based on what will deliver the greatest return on opportunity. Develops, implements, and manages oversight of the WOC/IPA under their purview.
- Determines the best course of action when facing challenges and makes recommendations on how best to approach a particular situation/barrier.
- Identify opportunities to improve Stars and Quality processes; methods, team engagement, and present resolution/options. Implement processes.
- Review and discuss provider/member/measure specific metrics and supporting collateral.
- Facilitate effective collaboration and communication with workgroup members (operations, clinical and MRA and quality team members). Provide input regarding assigned owned centers and IPA’s
- Schedule and conduct monthly meetings with physicians, center administrators, and other staff to discuss strategy aimed at achieving goals/targets.
- Conduct Site visits to centers and IPA’s to provide and review gap reports, score cards, coaching, opportunities, mitigation of barriers, best practices, etc.
- Critical thinking to prioritize PCP outreach based on what will deliver greatest return on investments (who to outreach, frequency of outreach, visit focus, communication method collateral).
- Deliver provider/member specific metrics and supporting collateral (HEDIS summary, Patient Experience, Rx opportunity, time-sensitive medication adherence reports) and coach providers and offices on improving all aspects of STARS performance to support achieving organizational targets (Conviva and Center Well).
- Responsible for Medicare STARS education. Conduct annual and ad hoc training/refresher to include measures changes specifications, CMS weight, etc. Ongoing education as applicable to recommend and best practices to enhance all aspects of STAR performance. Identify opportunities to improve Stars and Quality process; methods, team engagement, etc. and present resolution/options.
- Review and discuss Provider/member-specific metrics and supporting collateral (e.g., HEDIS Summary, Patient Experience, Rx opportunity, etc.) and coach providers on improving all aspects of Stars performance.
- Facilitate effective collaboration and communication with workgroup members (including operations, clinical, MRA) and Stars Quality team members. Participation in quality workgroup meeting. Providing input regarding assigned owned centers and/or IPA’s
- Schedule and hold regular meetings with physicians and other staff to discuss strategy aimed at achieving STARS/HEDIS targets/goals.
- Educate PCP’s and office staffs on Stars, Patient Experience, and Patient Safety with staff changes and best practices to enhance all aspects of Stars performance.
- Site visits to center and IPA’s to provide and review gap reports, score cards, as well as coaching opportunities for providers, and/or any others associates.
- Schedule and conduct medical record review (EMR or paper), retrieve records, and submit to payors for HEDIS gap closure to all health plans.
Use your skills to make an impact
Required Qualifications:
- Prior Experience in a fast paced insurance or health care setting.
- Experience in provider relations and education.
- Understanding of healthcare quality measures STARS, HEDIS, etc.
- Comprehensive knowledge of Microsoft Office Word, Excel, and PowerPoint.
- 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.
- Must reside in Florida and be willing to travel within the Orlando/Tampa area.
Preferred Qualifications:
- Bachelor's Degree.
- Prior RN/LPN or Center Administrator experience.
- Knowledge of Humana's internal policies, procedures and systems.
- Bilingual.
#LI-CM1
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$65,000 - $88,600 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of Humana’s Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva’s innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being.About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
