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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 focused on maternal health 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 which may include preventive care, maternal health, and identified medical metrics (ex. HEDIS, admissions, readmissions, ED utilization, polypharmacy, pre-term delivery rate, cesarean section rate, etc.). In this role, you will actively engage providers, review 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).

The Senior Stars Improvement, Clinical Professional will collaborate with internal stakeholders and leaders to analyze and inform strategies for improvement in maternal health outcomes for our members and the communities we serve.

Responsibilities:

• Continue to focus efforts and identify opportunities on performance improvement for assigned providers

• Actively engages provider during routine virtual visits to facilitate education, HEDIS and medical metric outcomes, care of members and bi-directional feedback.

• Attends joint operating committee meetings (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 developing strategies to reduce potential preventable events

• Educate providers and staff about Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

• Actively engage with internal stakeholders, leaders and teams to analyze and inform improvement strategies to address maternal health outcomes. Engagement may include formal and informal discussions, in individual or group settings.

Use your skills to make an impact
 

Required Qualifications

• FL RN License

• Must reside in the state of Florida

• Must have quality improvement experience in Medicaid or Medicare (Medicaid quality improvement a plus) (i.e. HEDIS, CMS Stars)

• 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

• Demonstrated ability to work independently, proactively initiate tasks, conduct thorough research, and acquire new knowledge to support ongoing development.

• 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

Preferred Qualifications

• Bachelor’s degree in nursing or related field

• Medical Coding Certification

• Certified Professional in Healthcare Quality (CPHQ)

• Knowledge of Humana's internal policies, procedures, and systems

• Medicaid Health Plan Experience

Additional Information

• Workstyle: Remote

• Work Location: Must reside in FL

• Travel: None