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Humana Gold Plus Integrated is seeking a Provider Engagement, Clinical Executive who will develop and grow positive, long-term relationships with physicians, providers and healthcare systems to support quality performance and improve member outcomes within the contracted working relationship with the health plan. The Provider Engagement, Clinical Executive works on problems of diverse scope and complexity ranging from moderate to substantial. They exercise independent judgment and decision making on complex issues regarding job duties and related tasks and work under minimal supervision. The Provider Engagement, Clinical Executive uses independent judgment requiring analysis of variable factors and determining the best course of action.

The Provider Engagement, Clinical Executive represents the scope of health plan/provider relationship across such areas as, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation and coding, HEDIS and STARs performance, and other areas as they relate to provider performance, member experience, market growth, and operational excellence. This work focuses on areas of clinical emphasis and advises executives to develop functional strategies (often segment specific) on matters of significance.

• Oversees plans and implements provider facing Quality Improvement (QI) initiatives, including scorecard development/monitoring, gaps in care reports, and CAHPS survey results/strategy.
• Collaborates with the market provider engagement/contracting/network optimization/practice transformation team to:  
• Develops provider engagement strategy, including Value – Based Programs (VBP), high-volume Fee-for-Service (FFS) and dual-eligible when applicable.
• Participates in meetings with providers and network teams (JOC, Clinical/Quality, Operation).
• Develop and/or standardize QI/clinical provider meeting presentations and reporting package.
• Creates market provider quality/clinical performance profiling and develop strategy to assist low performing providers to meet clinical targets.
• Develops EMR interoperability strategy.
• Key contributor to development and oversight of care coordination function (CCF) and outcome reporting.
• Key contributor to market planning sessions on provider risk readiness evaluation and timing.
• Key contributor to quality strategy for all provider facing activities, including participating in integrated care internal workgroups.
• Key contributor to market value-based provider incentive programs, including Primary Care Physician (PCP), specialist, and hospital.
• Department of Health and Family Services (HFS) and Center for Medicaid & Medicaid Services (CMS) point of contact for workgroups to develop provider strategies to improve member outcomes and close gaps.
• Liaison to providers to assist in developing strategies to improve clinical outcomes including but not limited to ER utilization, follow up after hospitalizations and preventive screenings.

Use your skills to make an impact
 

Required Qualifications

• Candidates must reside within a reasonable distance of Chicago, Illinois, in the states of Illinois, Indiana or Wisconsin.
• Bachelor’s degree.
• Five (5) or more years of experience in clinical strategy and implementation, focused on provider outcomes.
• Knowledge of quality metrics such as HEDIS and NCQA measures.
• Experience in healthcare, payor clinical programs, and value-based care organizations.
• Direct experience working with providers.
• Ability to drive cross functional teams to alignment.
• Demonstrated business and financial acumen.

Preferred Qualifications

• Registered Nurse (RN).
• Five (5) or more years’ experience in clinical practice working with or within a provider organization.
• Knowledge of an integrated care delivery system.
• Experience implementing QI initiatives and strategies.
• Experience using healthcare data and analytics to inform program development.

Additional Information

• Workstyle: This is a remote position with some travel.
• Travel: This role requires up to 10% travel to meet with provider groups within Illinois and occasional onsite meetings at Humana’s Schaumburg, IL office.
• Typical Work Schedule: Monday - Friday; 8:00 AM - 5:00 PM Central Standard Time (CST), with flexibility available.

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