In Home Eligibility Lead

Humana

10d • $115,200 - $158,400 • Remote

About The Position

The IHWA In‑Home Eligibility Lead is responsible for overseeing and managing eligibility strategy, execution, and data integrity for in‑home Quality Focused Visit (QFV) and related IHWA vendor programs. This role ensures accurate member targeting, consistent eligibility logic, and timely file delivery across multiple vendor partners, supporting high‑quality execution, Stars outcomes, and operational scalability. The Eligibility Lead partners closely with IHWA operations, Stars, analytics, IT, and external vendors to design and maintain eligibility criteria, minimize overlap across in‑home programs, and proactively identify and resolve eligibility risks. This role plays a critical part in translating program and quality requirements into executable eligibility rules, data files, and automated processes. Operating with a high degree of autonomy, the IHWA In‑Home Eligibility Lead analyzes complex data, exercises sound judgment, and drives continuous improvement in eligibility processes to support program growth, vendor performance, and member experience. The role also supports the transition from manual processes to automated, scalable solutions, ensuring readiness for future growth and evolving business needs.

Requirements

• Bachelor’s degree in business, healthcare administration, public health, information systems, or a related field; equivalent experience considered
• 5+ years of experience in healthcare operations, program delivery, eligibility management, or performance analytics
• Demonstrated experience managing eligibility criteria and file delivery across multiple vendors or partners
• Strong understanding of in‑home healthcare programs, quality initiatives, or Stars‑related workflows preferred
• Proven ability to work with complex data sets, including eligibility files, member lists, and disposition data
• Experience collaborating cross‑functionally with IT, analytics, operations, and vendor partners
• Strong analytical and problem‑solving skills, with the ability to identify eligibility risks, inconsistencies, or gaps
• Excellent communication skills, including the ability to explain complex eligibility logic to technical and non‑technical stakeholders
• Ability to manage multiple priorities and deadlines in a fast‑paced, high‑visibility environment
• Proficiency with SQL
• Proficiency with data and reporting tools (e.g., Excel, SQL, Power BI, Tableau, or similar)

Nice To Haves

• Experience supporting Quality Focused Visits (QFV) or similar quality‑driven in‑home programs
• Familiarity with Medicare Advantage, Stars measures, and member eligibility requirements
• Experience designing or managing daily eligibility file processes and automation initiatives
• Background in vendor governance, performance monitoring, or contract support
• Experience defining eligibility logic, prioritization rules, and exclusion criteria to minimize overlap and operational risk
• Knowledge of data governance, data quality controls, and audit readiness
• Experience working with APIs or automated data exchanges with external partners
• Master’s degree in healthcare administration, public health, data analytics, or a related field

Responsibilities

• Overseeing and managing eligibility strategy, execution, and data integrity for in‑home Quality Focused Visit (QFV) and related IHWA vendor programs.
• Ensuring accurate member targeting, consistent eligibility logic, and timely file delivery across multiple vendor partners.
• Partnering closely with IHWA operations, Stars, analytics, IT, and external vendors to design and maintain eligibility criteria.
• Minimizing overlap across in‑home programs.
• Proactively identifying and resolving eligibility risks.
• Translating program and quality requirements into executable eligibility rules, data files, and automated processes.
• Analyzing complex data, exercising sound judgment, and driving continuous improvement in eligibility processes.
• Supporting the transition from manual processes to automated, scalable solutions.
• Ensuring readiness for future growth and evolving business needs.

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level