Director, Clinical Quality Improvement

Humana•Tampa, FL

2d•Remote

About The Position

Become a part of our caring community and help us put health first The Director, Clinical Quality Improvement provides strategic leadership for Humana’s Florida Medicaid Quality Program, in alignment with organizational quality and population health goals and ensuring compliance with all contract, state, and federal requirements. They will support NCQA accreditation and will serve as the local market lead for accreditation compliance and achievement of HEDIS measurement standards through a collaborative effort. The Director, Clinical Quality Improvement, has oversight of quality and compliance processes, including evaluating and tracking investigations into quality-of-care concerns. This position has primary responsibility to operate a quality management infrastructure which promotes member safety, quality of care, improves health disparities, is culturally responsive and assures cost effective access to care in the safest, least restrictive setting. This role requires commitment to cross-functional collaboration to drive continuous quality improvement throughout health plan operations, provider network and community partnerships to achieve our quality improvement goals and objectives. Operate an NCQA compliant quality program. Manage, develop and coach 2 direct and 20 indirect reports. Oversee the development, implementation and management of quality improvement projects and work collaboratively to address health equity and social determinants of health. Partner with the CMO and Population Health Director to inform population health strategy and target improvement areas including the design of clinical programs that improve health outcomes and reduce health disparities. Oversee HEDIS and CAHPS required measure reporting, evaluation, and improvement. Ensure compliance with quality-of-care investigations and reporting Provide oversight of the Annual Quality Program Description, Annual Quality Work Plan, and the Annual Quality Program Evaluation. Improve quality measure performance through innovative approaches in engaging members and providers. Oversee the medical record and treatment record review processes for the plan Analyze dashboards consisting of Key Performance Indicators (KPI), and non-KPI metrics, interpreting trends and significant variances as opportunities to improve outcomes. Incorporate actionable analytics, utilizing business intelligence tools, care coordination tools, and claims systems to identify issues, mitigate risks, and develop solutions. Serve on standing committees of governance and quality management. Responsible for maintaining confidential information in accordance with policies, and state and federal laws, rules and regulations regarding confidentiality Maintaining/Updating policies and procedures and program descriptions Use your skills to make an impact

Requirements

FL RN License or equivalent clinical license such as APRN
Must reside in the state of Florida
5 or more years of clinical and management experience
3 or more years of quality improvement experience in Medicaid or Medicare (Medicaid quality improvement a plus) (i.e. HEDIS, CMS Stars)
Travel within the FL area up to 25% of the time
Prior experience in a fast-paced insurance or health care setting
Experience in provider relations and education
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

Nice To Haves

Bachelor’s degree in Nursing and/or Advanced Degree
Knowledge of Humana's internal policies, procedures and systems

Responsibilities

Operate an NCQA compliant quality program.
Manage, develop and coach 2 direct and 20 indirect reports.
Oversee the development, implementation and management of quality improvement projects and work collaboratively to address health equity and social determinants of health.
Partner with the CMO and Population Health Director to inform population health strategy and target improvement areas including the design of clinical programs that improve health outcomes and reduce health disparities.
Oversee HEDIS and CAHPS required measure reporting, evaluation, and improvement.
Ensure compliance with quality-of-care investigations and reporting
Provide oversight of the Annual Quality Program Description, Annual Quality Work Plan, and the Annual Quality Program Evaluation.
Improve quality measure performance through innovative approaches in engaging members and providers.
Oversee the medical record and treatment record review processes for the plan
Analyze dashboards consisting of Key Performance Indicators (KPI), and non-KPI metrics, interpreting trends and significant variances as opportunities to improve outcomes.
Incorporate actionable analytics, utilizing business intelligence tools, care coordination tools, and claims systems to identify issues, mitigate risks, and develop solutions.
Serve on standing committees of governance and quality management.
Responsible for maintaining confidential information in accordance with policies, and state and federal laws, rules and regulations regarding confidentiality
Maintaining/Updating policies and procedures and program descriptions