Remote Director, Quality Improvement – Medicaid

Location: WI
Location Type: Remote
Additional Location: AL; AZ; AR; CA; CO; CT; DE; FL; GA; ID; IL; IN; IA; KS; KY; LA; ME; MD; MA; MI; MN; MS; MO; MT; NE; NV; NH; NJ; NM; NY; NC; ND; OH; OK; OR; PA; RI; SC; SD; TN; TX; UT; VT; VA; WA; WV; WY;
Schedule: Full_time
Req: R-321087

Description

Humana is a Fortune 40 market leader in integrated healthcare whose dream is to help people achieve lifelong well-being. As a company focused on the health and well-being of the people we serve, Humana starts from within, and is committed to providing progressive benefits that advance 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.

Responsibilities

The Director, Quality Improvement provides strategic leadership for Humana’s Wisconsin Medicaid Quality Program, in alignment with organizational quality and population health goals and ensuring compliance with all contracts, state, and federal requirements. They will support NCQA accreditation and will serve as the local market lead for accreditation compliance. The Director, Quality Improvement has oversight of quality investigations and compliance processes, including evaluating and investigations into quality-of-care concerns. This position has primary responsibility to operate a quality management infrastructure which promotes member safety, quality of care, improves health disparities, is culturally competent and assures cost effective access to care in the safest, least restrictive setting. This role requires commitment to cross-functional collaboration to drive continuous quality improvement throughout health plan operations, provider network and community partnerships to achieve our quality improvement goals and objectives.

• Operates an NCQA compliant quality program.
• Oversees the development, implementation and management of quality improvement projects and work collaboratively to address health equity and social determinants of health.
• Partners with Population Health Director to inform population health strategy and target improvement areas including the design of clinical programs that improve health outcomes and reduce health disparities.
• Oversees HEDIS, CAHPS, and DMS required measure reporting and evaluation.
• Ensures compliance with quality-of-care investigations and reporting.
• Provides oversight of the Annual Quality Program Description, Annual Quality Work Plan, and the Annual Quality Program Evaluation.
• Improves quality measure performance through innovative approaches in engaging members and providers.
• Analyzes dashboards consisting of Key Performance Indicators (KPI), and non-KPI metrics, interpreting trends and significant variances as opportunities to improve outcomes.
• Incorporates actionable analytics, utilizing business intelligence tools, care coordination tools, and claims systems to identify issues, mitigate risks, and develop solutions.
• Serves on standing committees of governance and quality management.
• Responsible for maintaining confidential information in accordance with policies, and state and federal laws, rules, and regulations regarding confidentiality.

Required Qualifications

• Registered Nurse (RN), physician or physician’s assistant licensed in the state of Wisconsin without restrictions or be certified as a Certified Professional in Health Care Quality by the National Association for Healthcare Quality (NAHQ), Certified QI Associate by the American Society for Quality, and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. If candidate does not possess one of the certifications, they must obtain certification(s) within 6 months from date of hire.
• Associate degree in nursing, education, public health, health administration, health policy or business.
• Minimum five (5) years of experience in Quality Improvement/Quality Assurance in the healthcare field.
• Minimum three (3) years of leadership experience.
• Prior Medicare or Medicaid health plan experience.
• Clinical program development and implementation experience.
• Strong understanding of NCQA Health Plan accreditation standards and requirements.
• Demonstrated skills in quality improvement concepts, health care data analysis, data mining methods and the identification of population health issues, trends, and health disparities using health care data sources.
• Understanding of value-based payment models that reward quality improvement.
• Understanding of cultural factors that influence health outcomes and implementing culturally competent improvement interventions.
• Excellent communication skills and experience in cross-functional collaboration in matrixed organizations.

Preferred Qualifications

• Master’s Degree in nursing, public health, health administration, health policy or business.
• CPHQ (Certified Professional in Healthcare Quality) Certification.
• Knowledge of Humana’s internal policies, procedures, and systems.

Additional Information

• Workstyle: This is a Remote position with travel.
• Travel: Up to 25% to Humana’s office locations and external agencies within the state of Wisconsin.
• Workdays & Time: Monday – Friday; Central Standard Time.

Work at Home Criteria

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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.
• Employees 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 employees 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 using an interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

#LI -JW

Scheduled Weekly Hours

40

Pay 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 decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$112,400 – $154,900 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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.