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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 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).

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.

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
• 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

• FL BSN License (Bachelor's Degree in Nursing)
• Medical Coding Certification
• 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
• Typical Workdays/Hours: Monday- Friday, 8am- 5pm EST

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Interview Format

As part of our hiring process for this opportunity, we will be u