Director, Clinical Quality Improvement

Become a part of our caring community and help us put health first

The Director, Clinical Quality Improvement provides strategic leadership for Humana’s Florida Medicaid Quality Program, in alignment with organizational quality and population health goals and ensuring compliance with all contract, state, and federal requirements. They will support NCQA accreditation and will serve as the local market lead for accreditation compliance and achievement of HEDIS measurement standards through a collaborative effort.

The Director, Clinical Quality Improvement, has oversight of quality and compliance processes, including evaluating and tracking 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 responsive 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.

• Operate an NCQA compliant quality program.

• Manage, develop and coach 2 direct and 20 indirect reports.

• Oversee the development, implementation and management of quality improvement projects and work collaboratively to address health equity and social determinants of health.

• Partner with the CMO and 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.

• Oversee HEDIS and CAHPS required measure reporting, evaluation, and improvement.

• Ensure compliance with quality-of-care investigations and reporting

• Provide oversight of the Annual Quality Program Description, Annual Quality Work Plan, and the Annual Quality Program Evaluation.

• Improve quality measure performance through innovative approaches in engaging members and providers.

• Oversee the medical record and treatment record review processes for the plan

• Analyze dashboards consisting of Key Performance Indicators (KPI), and non-KPI metrics, interpreting trends and significant variances as opportunities to improve outcomes.

• Incorporate actionable analytics, utilizing business intelligence tools, care coordination tools, and claims systems to identify issues, mitigate risks, and develop solutions.

• Serve 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

• Maintaining/Updating policies and procedures and program descriptions

• FL RN License or equivalent clinical license such as APRN

• Must reside in the state of Florida

• 5 or more years of clinical and management experience

• 3 or more years of quality improvement experience in Medicaid or Medicare (Medicaid quality improvement a plus) (i.e. HEDIS, CMS Stars)

• Travel within the FL area up to 25% of the time

• Prior experience in a fast-paced insurance or health care setting

• Experience in provider relations and education

• Comprehensive knowledge of Microsoft Office Word, Excel and Power Point

• Proven analytical skills

• 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

• Bachelor’s degree in Nursing and/or Advanced Degree

• Knowledge of Humana's internal policies, procedures and systems

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 using exciting interviewing technology called Hire Vue to enhance our hiring and decision-making ability. Hire Vue allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first-round interview, you will receive an email…