United States onlyBecome a part of our caring community and help us put health first
Humana is seeking a Quality Compliance Nurse to support the Wisconsin Medicaid market. This role performs duties to support optimized performance on key quality indicators including, but not limited to, HEDIS, 5 Star, Pay-for-Performance (P4P), satisfaction surveys, Annual Quality Reviews (AQR), and External Quality Reviews (EQR). The Quality Compliance Nurse fosters a culture of quality improvement by designing projects and studies in collaboration with appropriate teams that directly impacts members by ensuring data accuracy in reporting, investigation, auditing, and improvement opportunities.- Assist with the overall Quality Assessment Performance Improvement (QAPI) program including compliance with State, Federal, and other managed care regulatory bodies, QAPI mandates, audits, performance improvement projects and reports.
- Use continuous Quality Improvement process through tracking and trending data including clinical analysis and reporting for quality monitoring and improvement.
- Ensure data integrity/maintain efficiency of data collection/maintenance systems.
- Provide clinical direction as needed to staff dedicated to grievance/appeals and credentialing/re-credentialing functions; and as needed to staff dedicated to review, analysis and response to quality concerns, reportable incidents, and statements of deficiency.
- Assist with and provide clinical direction as needed to design, implement, and analyze mandated quality and performance improvement projects.
- Assist department director in the development, maintenance, and execution of quality documents including work plan, evaluation, program description, and Model of Care (as appropriate for Medicare).
- Provide technical and content-specific expertise to other departments relevant to the identification of, tracking and analysis, and remediation of quality concerns.
- Perform internal audit reviews of system processes to ensure compliance with regulations, polices, procedures.
- Track, trend, synthesize, develop, and distribute written information and reports for internal and external requirements regarding the following: QAPI program; and QI activities (studies, surveys, audits, peer reviews, etc.)
- Assist in the development, implementation, analysis, and follow-up for performance improvement, chronic care improvement, and quality improvement programs.
- Analyze and investigate quality of care concerns, reportable incidents, Statements of Deficiencies (SOD).
- Coordinate as needed with partners to schedule and re-schedule reviews/audits.
- Accurately complete provider (acute, primary, long term care, etc.) audits (may include medical record reviews).
- Assist in development, implementation, and analysis of satisfaction surveys (provider and member).
- Assist in the preparation of improvement action plans when deficiencies are identified, monitors and assures that re-evaluation activities are completed and recommendations for improvement have been implemented.
- Represent Humana/iCare on pertinent internal and external committees and appropriate meetings.
- Provide clinical direction as needed to non-clinical QI personnel.
- Participate in the preparation of materials for Quality Management & Improvement Committee (QMIC), Long-Term Care Quality Improvement Committee (LTC-QIC), and the Care Management Quality Improvement Committee (CM-QIC).
- Assist department management in the development and implementation of new programs for improving and sustaining operating effectiveness and efficiencies.
- Gain subject matter expertise in existing analytical tools, and clinical dashboards while providing feedback and guidance in the selection and development of new tools.
- Analyze data to produce reports and clinical dashboards used in developing strategies and activities for improvement.
- Collaborate with Care Management Department in the implementation of performance initiatives to ensure improvement in HEDIS, 5-Star, Pay for Performance initiatives, and any other contract compliance quality performance projects.
- Collaborate with Network Development Department in the implementation of acute, primary and long-term-care provider monitoring.
Use your skills to make an impact
Required Qualifications
- State of Wisconsin licensed RN or have a compact license.
- 2 years of experience working as an RN.
Preferred Qualifications
- Experience with data collection, analysis and reporting and working with the continuous Quality Improvement process.
- Prior work experience with and knowledge of both Medicare and Medicaid.
- 1-3 years managed health quality assurance experience.
- Experience leading quality improvement plan development and implementation.
- Prior work experience and knowledge of Long Term Care.
Additional Information
- Workstyle: Home. Home workstyle is defined as remote but will use Humana office space on an as needed basis for collaboration and other face-to-face needs.
- Typical Work Days/Hours: Monday – Friday, 8:00 am – 5:00 pm CST.
WAH Internet Requirements
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.
HireVue
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.
SSN Alert
Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.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.$71,100 - $97,800 per yearThis 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.
About us
About Inclusa: Inclusa manages the provision of a person-centered and community-focused approach to long-term care services and support to Family Care members across the state of Wisconsin. As a values-based organization devoted to building vibrant and inclusive communities, Inclusa deploys a unique approach to managed care with a trademarked model of support named Commonunity® which focuses on the belief in everyone, and from that belief, the common good for all is achieved. In 2022, Inclusa was acquired by Humana. This partnership will allow us to create a model of care that provides industry-leading support for members across the health care continuum.About Humana: Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our 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, Medicaid, families, individuals, military service personnel, and communities at large.
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.
