Senior Stars Improvement, Clinical Professional BSN/RN

Humana

3d•Remote

About The Position

Become a part of our caring community and help us put health first The Senior Stars Improvement, Clinical Professional responsible for the development, implementation and management oversight of the company's Medicare/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 Senior Stars Improvement, Clinical Professional is responsible for a provider assignment of 50+ Medicaid provider groups. This position oversees HEDIS, quality & performance improvement and required quality activities that are related to NCQA health plan performance rating as well as the Agency’s Quality Withhold and Liquidated Damages programs for assigned providers. Also supports improvement strategies through engagement with internal and external stakeholders. The Senior Stars Improvement, Clinical Professional monitors assigned value-based and non-value-based provider/provider groups’ performance in key performance indicators related to preventive care, care of chronic conditions and identified medical metrics (ex. HEDIS, APT, readmissions, ED utilization, polypharmacy, etc.). In this role, you will actively engage providers, review of KPIs, improvement strategies and bi-directional feedback related to barriers and opportunities. Educate and assist providers in reducing potential preventable events through the use of data driven methods and resources related to available clinical programs. Support improvement in member experience through education, information and resources related to the annual Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and Humana’s Member Experience Medicaid Survey (MEMS).

Requirements

FL RN License
Must reside in the state of Florida
Must have two years of prior HEDIS, STARS and/or quality improvement experience in Medicaid or Medicare (Medicaid quality improvement a plus).
Proficient/ intermediate utilization of Excel and PowerPoint.
Prior experience in a fast-paced insurance or health care setting
Experience collaborating with cross-functional teams
Proven analytical skills
Excellent communication skills, both oral and written
Strong relationship building skills
Conducts self in a professional manner with all verbal and written communication when working with associates, peers, and providers
Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Nice To Haves

FL BSN License (Bachelor's Degree in Nursing)
Medical Coding Certification
Knowledge of Humana's internal policies, procedures, and systems
Medicaid Health Plan Experience

Responsibilities

Continue to focus efforts and identify opportunities on performance improvement for assigned providers
Actively engages provider during virtual visit to facilitate education, HEDIS outcomes, care of members and bi-directional feedback.
Attends JOCs with providers and participates in active discussions on HEDIS, member care, and clinical/quality outcomes.
Communicate clinical quality initiatives to assigned providers
Educate and assist providers in reducing potential preventable events
Educate providers and staff about Medicaid Consume Assessment of Healthcare Providers and Systems (CAHPS) survey.