Position Responsibilities:
Research best business practices within and outside the organization to establish benchmark data.
Collect and analyze process data to initiate, develop, and recommend business practices and procedures that focus on enhanced safety, increased productivity, and reduced cost.
Performs CMS and State audits focused on improving compliance and quality.
Focus audits – may include annual and initial HRA compliance, Critical Incident audits, post discharge and transition of care contacts.
Provide Source System Validations for Universe and State reports
Prepare cases, present cases and/or provide navigation responsibilities for CMS audits and State audits
Participate and present in reports for Quality Improvement Committee and other committees as needed
Collaborate with Managers, Senior Care Coordinators and Care Coordination staff for remediations identified on audits
Assist in special projects as needed
Development and review of internal quality metrics.
Support process improvement initiatives.
Assist in reviewing new Job Aids to support the team of Learning Design and Learning Facilitation staff.
Review current Job Aids and Policies and Procedures as requested.
Create and present education as requested by the Process Improvement Lead.
Supports Operations Managers in quality improvement initiatives.
Assist Managers in communicating audit findings to individuals and teams.
Participates in Interrater Reliability (IRR) meetings and assists in the development of Interpretation Standards to guide audit scoring and increase consistency across the Process Improvement Team.
Participates in root cause analysis research for audits.
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
Required Qualifications
Bachelor's degree
2 years of experience related to process improvement, compliance measures, or auditing practices or 2 years of experience in Medicaid/Medicare Care Coordination
Ability to travel to Schaumburg office at minimum 2- 4 times yearly for State and CMS Mock audits
Occasional travel to Louisville for an extended period during CMS Audits
Proven oral / written communication and presentation skills.
Excellent analytical skills, able to manipulate and interpret data
Exceptional organizational and prioritization skills.
Comprehensive knowledge of Microsoft Office Word, Excel, and PowerPoint.
Ability to work within highly structured contractual time compliance requirements with occasional short turnaround time.
Preferred Qualifications:
Knowledge of HEDIS/Stars/CMS/Quality.
Experience in Medicaid or Medicare Guidelines.
Detail orientated and comfortable working with tight deadlines in a fast-paced environment
Additional Information
Workstyle: Remote
Travel: Travel may be required to support state and federal audits.
Core Workdays & Hours: Monday – Friday; typically, 8:00am – 5:00pm Central Standard Time.
Work at Home Requirements
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.
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.
Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.