Become a part of our caring community

If you are passionate about Clinical Quality and enjoy being responsible for ensuring the company is prepared for audits that impact Humana’s certification and accreditation status, this may be the role for you. The Senior Quality Improvement Professional implements quality improvement programs for all lines of business including annual program description, work plan, and annual evaluation. The Senior Quality Improvement Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. 

Success in the Senior Quality Improvement Professional role will require:

Clinical Skills and Knowledge

• Exhibits proficient knowledge of HEDIS Supplemental and Hybrid seasonal requirements and processes as they relate to the internal audit process.
• Leverages clinical knowledge and experience to audit medical record reviews.
• Ensures compliance with HEDIS Technical Specifications and provides feedback to improve reviewer quality and ensure all practices are consistent with external audit/NCQA requirements.

Expanded Data and Quality Competencies

• Demonstrates understanding of end‑to‑end clinical data flows, including provider data submission (e.g., EHRs, HIEs/registries, remote monitoring), data mapping and normalization, vendor ingestion of CQL‑based measures, and automated return of results to health plan systems.
• Proven ability to interpret, validate, and troubleshoot CQL‑based clinical quality measure logic to ensure accurate implementation and measurement across data sources and platforms.
• Strong expertise in validating data lineage and traceability, including mapping accuracy and integrity from source through all stages of transformation and use.
• Experience validating not only primary source verification (PSV) but also upstream and downstream data pipelines to ensure data accuracy, consistency, and reliability throughout the data lifecycle.
• Working knowledge of evolving NCQA requirements for electronic clinical data systems, digital measures, and CQL, with the ability to adapt audit and validation approaches accordingly.
• Foundational understanding of SQL desired, including the ability to read, interpret, and validate existing queries.

Execution for Results

• Leverages resources to create exceptional outcomes, driving quality improvement of nurse reviewer KPIs and ensuring the integrity of HEDIS data through all stages of transformation and utilization.

Pursuit of Excellence

• Seeks growth opportunities from available resources.
• Exhibits ample focus, attention to detail, reliability, and flexibility to reprioritize work as needed to drive outcomes.

Organization

• Demonstrates agility and adaptability in an environment of frequent organizational change.
• Contributes to feedback loop with audit leadership and team – communicating pertinent information related to reviewer errors and error trending, as well as stakeholders involved in HEDIS data ingestion, transformation, and utilization.

Accountability

• Meets role expectations and takes responsibility for actions, utilizing result of actions as learning and growth opportunities.

Job Activities:

Computer/Data Systems

• Utilize role-specific technological tools and applications to collect, interpret, and process data.
• Verifies conformity between member information and measure data in medical records, HEDIS Technical Specifications, Humana systems, and pseudo-claim/gap data entered by nurse reviewers.
• Enters/documents all audit findings into PowerApps-based audit data entry system and Rapid Retrieve annotations.
• Generates and distributes error notifications as needed to provide reviewer redirection/opportunity for course correction, thereby reducing risk of further errors.
• Validates integrity of data pipelines to ensure accuracy, consistency, and integrity throughout the lifecycle.

Obtaining/Utilizing Key Data

• Obtain and/or enter relevant data utilizing the following systems and resources: Cotiviti Rapid Retrieve, Quality Reporter Web, OSQR/PPI, PMDM, MRM, MS OneNote, HEDIS Technical Specifications, HEDIS Value Set Directory, MS SharePoint, and various claims systems.

Communicating with Supervisors, Peers and Others

• Openly communicates and shares ideas related to the audit process and quality improvement opportunities.
• Alerts leadership of error trending and system issues as they arise.
• Demonstrates a strong proclivity for teamwork and collaboration with audit team members and stakeholders across QSI and the Stars organization.

Making Decisions/Solving Problems

• Analyzes information and evaluates results to choose the best solution and solve problems.
• Willingness to collaborate in determining best solution.

Updating Relevant Knowledge

• Attends all required meetings, stays abreast of all information pertinent to role and responsibilities, including but not limited to evolving NCQA requirements and related electronic data systems.

Special Audit Projects

• Flexible to performing special audits on an as-needed basis (e.g., Mock Audits of Attestations (SQR/EAF), NLP audits, and audits of Artificial Intelligence system outputs), including audits that require provider outreach.
• Assist with biannual external/NCQA PSV and MRRV audit validation and submission process.

Use your skills to make an impact

Required Qualifications

• Bachelor’s Degree
• 5 years of health plan experience
• HEDIS experience
• Clinical audit experience
• Proficient in data analysis
• Foundational knowledge of SQL
• Proficient in Microsoft Office applications (e.g., Excel, Word, Outlook, and Teams) and Zoom

Preferred Qualifications

• Licensed Clinician (e.g., RN license with no restrictions or disciplinary action)
• CPHQ certification
• Foundation knowledge of Lean/Six Sigma and/or certification

Travel: While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required. 

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

$78,400 – $107,800 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. 

Application Deadline: 06-14-2026

About us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. 

​
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.