Quality Improvement Professional

Become a part of our caring community

The Quality Improvement Professional II will facilitate and work collaboratively with employed physicians (owned centers) and independent providers (IPA) in the Conviva network to provide support guidance, make recommendations and develop practice specific strategies designed to improve Medicare quality measures (HEDIS) as well as patient safety and patient experience (CAHPS-HOS).

You will monitor quality investigations and compliance procedures/processes. Manages quality management systems, department Sharepoint and departmental reporting. Audits processes as needed for compliance. Understands departmental segments organizational strategy and operating objectives including their linkages to related areas. Make decisions regarding own work methods, occasionally in ambiguous situations and requires minimal direction and receives guidance when needed.

Responsibilities:

• Quality Improvement Professional assigned to each market applies critical thinking to prioritize center/IPA outreach based on what will deliver the greatest return on opportunity. Develops, implements, and manages oversight of the WOC/IPA under their purview.

• Determines the best course of action when facing challenges and makes recommendations on how best to approach a particular situation/barrier.

• Identify opportunities to improve Stars and Quality processes; methods, team engagement, and present resolution/options. Implement processes.

• Review and discuss provider/member/measure specific metrics and supporting collateral.

• Facilitate effective collaboration and communication with workgroup members (operations, clinical and MRA and quality team members). Provide input regarding assigned owned centers and IPA’s

• Schedule and conduct monthly meetings with physicians, center administrators, and other staff to discuss strategy aimed at achieving goals/targets.

• Conduct Site visits to centers and IPA’s to provide and review gap reports, score cards, coaching, opportunities, mitigation of barriers, best practices, etc.

• Critical thinking to prioritize PCP outreach based on what will deliver greatest return on investments (who to outreach, frequency of outreach, visit focus, communication method collateral).

• Deliver provider/member specific metrics and supporting collateral (HEDIS summary, Patient Experience, Rx opportunity, time-sensitive medication adherence reports) and coach providers and offices on improving all aspects of STARS performance to support achieving organizational targets (Conviva and Center Well).

• Responsible for Medicare STARS education. Conduct annual and ad hoc training/refresher to include measures changes specifications, CMS weight, etc. Ongoing education as applicable to recommend and best practices to enhance all aspects of STAR performance. Identify opportunities to improve Stars and Quality process; methods, team engagement, etc. and present resolution/options.

• Review and discuss Provider/member-specific metrics and supporting collateral (e.g., HEDIS Summary, Patient Experience, Rx opportunity, etc.) and coach providers on improving all aspects of Stars performance.

• Facilitate effective collaboration and communication with workgroup members (including operations, clinical, MRA) and Stars Quality team members. Participation in quality workgroup meeting. Providing input regarding assigned owned centers and/or IPA’s

• Schedule and hold regular meetings with physicians and other staff to discuss strategy aimed at achieving STARS/HEDIS targets/goals.

• Educate PCP’s and office staffs on Stars, Patient Experience, and Patient Safety with staff changes and best practices to enhance all aspects of Stars performance.

• Site visits to center and IPA’s to provide and review gap reports, score cards, as well as coaching opportunities for providers, and/or any others associates.

• Schedule and conduct medical record review (EMR or paper), retrieve records, and submit to payors for HEDIS gap closure to all health plans.

Use your skills to make an impact

Required Qualifications:

• Prior Experience in a fast paced insurance or health care setting.

• Experience in provider relations and education.

• Understanding of healthcare quality measures STARS, HEDIS, etc.

• Comprehensive knowledge of Microsoft Office Word, Excel, and PowerPoint.

• 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.

• Must reside in Florida and be willing to travel within the Orlando/Tampa area.

Preferred Qualifications:

• Bachelor's Degree.

• Prior RN/LPN or Center Administrator experience.

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

• Bilingual.

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