Quality Improvement Professional

Humana

10d • $65,000 - $88,600 • Remote

About The Position

Become a part of our caring community and help us put health first The Quality Improvement Professional plays an important role in auditing vendor agencies providing service coordination to member within the Pathways program. You will assess vendor performance, ensuring compliance with contractual obligations and quality standards, and improving service delivery. While the primary focus is on auditing vendor operations, you should also be prepared to provide support in service coordination activities. This ensures the delivery of high-quality services and positive outcomes for our program participants. The Service Coordinator (Quality Auditor) role involves conducting quality audits and may require onsite visits to vendor agencies throughout the state of Indiana. When supporting service coordination activities, your work will involve meeting members in their location to spend quality time assessing their needs and barriers and then connecting our member with quality services.

Requirements

• Bachelor's degree or equivalent
• Must reside in Indiana
• 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
• Must be passionate about contributing to an organization focused on improving consumer experiences
• Valid state driver's license
• Proof of personal vehicle liability insurance with at least $100,000/$300,000/$100,000 limits
• Access to a reliable vehicle

Nice To Haves

• RN license
• Knowledge of Humana's internal policies and systems

Responsibilities

• Conduct audits and evaluations of vendor agencies to assess compliance with contractual requirements, and quality standards.
• Provide input to improve the quality and effectiveness of service coordination provided by vendor agencies, including developing action plans based on audit findings and implementing process improvements.
• Provide support, guidance, and training to vendor agencies to enhance their compacity to deliver high quality service coordination.
• Analyze audit findings, tends and performance metrics to identify areas for improvement.
• Administer ongoing long-term services and support (LTSS) related assessments through person-centered thinking approaches.
• Contacts members both telephonically and/or in-person to establish goals and priorities. This involves evaluating resources, developing a plan of care, and identifying LTSS providers and community partnerships. The goal is to provide a combination of services and supports that best meet the needs and goals of the member and caregiver through person-centered thinking approaches.
• Development and modification of Service Plan and involve applicable members of the care team in care planning (Informal caregiver coach, PCP, etc.)
• Support members through navigation of their LTSS and related environmental and social needs
• Use available information about member to prevent the need for administration of duplicative assessments.
• Focus on supporting members or caregivers in accessing long-term services and support, social, housing, educational and other services, regardless of funding sources to meet their needs.
• Build trust and promote independence through a collaborative relationship with the Care Coordinator, member, and caregiver.
• Identify transition opportunities and work closely with transition coordinators to support member choice.
• Coordinating with Care Coordinator on referrals for non-capitated services and capturing all services the member is receiving (regardless of payer), including their natural supports.
• Coordinating and consulting with Humana-contracted providers regarding delivery of LTSS services
• Participate in interdisciplinary Care team meetings (ICT)
• Connect and refer members to community resources and third-party payers
• Assist members in maintaining Medicaid eligibility
• Collaborate with Medical Director/Geriatrician/Care Coordinator as deemed necessary to ensure cohesive, holistic service delivery positive member outcomes.

Benefits

• Humana provides 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 and many other opportunities.

What This Job Offers

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