Responsibilities
The Senior Quality Compliance Professional completes medical records reviews for Coordination of Care studies. Analyzes data and implement corrective actions as needed. Reviews medical records for supplemental data and enter data in supplemental data base. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
Additional Responsibilities Will Include:
Implements quality programs for the South Carolina Medicaid line of business including annual program description, work plan, annual evaluation, and compliance and Coordination of Care activities.
Completes medical record review documentation audits, including supplemental data through the analysis of data and implement corrective actions as needed.
This position requires a solid understanding of how organization capabilities interrelate across department(s). Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area.
Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.
Will work additional Responsibilities based on business need
Required Qualifications
Bachelor’s degree
RN License for State of SC required
Prior experience in working with quality metrics in a fast paced insurance or health care setting
Experience with Medicaid programs
3-4 years experience with compliance and/or quality
Clinical experience in a health care setting, preferably acute care
Demonstrated management experience and ability to partner with senior leadership on strategic initiatives
Strong Clinical Quality experience
Demonstrated ability to manage multiple projects and meet deadlines specifically in DMAIC and PDSA style reporting and analysis.
Comprehensive knowledge of all Microsoft Office applications
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Comprehensive knowledge of Microsoft Word, Excel and PowerPoint
Excellent communication skills, both oral and written
Strong relationship building skills
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required.
Preferred Qualifications
Quality HEDIS GAP closure experience
Knowledge of Humana’s internal policies, procedures and systems
Experience working with healthcare providers within a managed care setting
Additional Information
For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to:
Provide proof of full vaccination or commit to testing protocols OR
Provide proof of applicable exemption including any required supporting documentation
Medical, religious, state and remote-only work exemptions are available.
Scheduled Weekly Hours
40