Become a part of our caring community and help us put health first
 

Humana is a $100 billion (Fortune 42) market leader in integrated healthcare with a clearly defined purpose to help people achieve lifelong well-being. As a company focused on the health and well-being of the people we serve, Humana is committed to advancing the employment experience and vitality of the associate community. Through offerings anchored in a whole-person view of human well-being, Humana embraces a focus on stimulating positive individual and population changes while nurturing a sense of security, enabling people to live life fully and be their most productive.

Against that backdrop, we are seeking a talented executive for the position of Vice President (VP), HQRI Operations. This position plays a crucial role leading and driving strategic initiatives to optimize risk adjustment operations and solutions that deliver quality outcomes and business value. This role impacts our overall Medicare and Medicaid strategy, as it impacts the revenue needed to fund benefits.

               

The VP, HQRI Operations will create and own the strategic plan for enterprise risk adjustment operations.  This position will report directly to the SVP, Risk Adjustment and Interoperability and lead a multi-level organization of more than 500 associates, with approximately 5 direct reports. This position will have coordination and oversight of multiple vendors including medical record retrieval and coding vendors, as well as all internal operational partners.  This position will have oversight and support of all Medicare Market MRA functions.

 

The VP, HQRI Operations can be located anywhere within the contiguous United States, although a major city in the Eastern U.S. would be ideal.  Moderate travel (~20%) should be expected.

 

Key Responsibilities

• Responsible for all Operations within Risk Adjustment, including but not limited to

• Medical Record Retrieval for all Medicare and Commercial Risk Adjustment functions (retrospective review and all compliance and audit processes) and HEDIS

• Coding Operations for Medicare and Commercial Risk Adjustment

• Management of multiple vendors who provide workflow, retrieval and coding operations, imaging vendors and provider outbound call center vendor

• Encounter submissions on EDS while creating efficiencies through technology functions for Medicare, Commercial and Medicaid and implementation of any new states for Medicaid

• Dual Eligible Outreach team – outbound member call center responsible for Medicaid activations

• Oversight and support of all market MRA functions, and being the centralized function to coordinate all activities, including re-rentry, productivity, and serve as single coordination point for market Risk Adjustment Operations (serves as functional resource for Segment Presidents to ensure consistency)

• Training and education for all risk adjustment functions

• Policies and procedures for all risk adjustment functions

Use your skills to make an impact
 

Key Candidate Qualifications

The ideal candidate will have extensive leadership experience (typically 10+ years) in the healthcare industry, specifically in risk adjustment operations. He/she will have expertise in the development and execution of operational strategies along with a record of success working in a highly matrixed environment. Finally, this person will be a strong leader of people with proven success in expanding and elevating the capabilities and performance of a multi-level team and large-scale organization.

 

In addition, the following professional credentials and personal attributes are also sought:

• Bachelor’s degree in healthcare administration, business, or a related field. Master’s degree is highly desired.

• In-depth understanding of partners/functions within and outside the segment. Understanding of how organization capabilities interrelate across segments and enterprise-wide.

• Demonstrated ability in building strategic relationships with internal and external parties, including cross-functional partners, corporate and market functions, vendors and providers.

• Deep knowledge of the health