DescriptionThe Quality Improvement Consultant develops, implements, and manages oversight of the company's Medicare/Medicaid Stars Program. Directs all Stars quality improvement programs and initiatives. The Quality Improvement Consultant work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
Role: Quality Improvement Consultant, RN
Location: Tucson, AZ (Pima and Cochise County area)
This position will require frequent day travel throughout the Pima and Cochise County area which includes Tucson and surrounding markets. The Quality Improvement Nurse Consultant works as part of an interdepartmental team of around 5 members, working collaboratively with providers. Focus of work is to help providers with HEDIS measures and improve the quality of care received by the member. The team will work collaboratively with provider groups focused on Senior Product plans to guide, recommend and develop practice specific strategies designed to improve HEDIS scores and all aspects of quality. Primary responsibilities include:
- Qualify, prioritize, and concentrate Provider visit efforts on top opportunities
- Develop, facilitate, and/or secure opportunities to positively impact Triple Aim
- Maintain client relationships, effectively address provider needs & team goals
- Understand the business, industry, and industry trends and use knowledge to recommend effective solutions.
- Lead and/or support collaborative business partnerships, elicit client understanding and insight to advise and make recommendations.
- Clarify scope of work commitments and deliverables, and define measurable success criteria to monitor progress toward goals.
- Deliver provider specific metrics and coach providers on gap closing opportunities
- Facilitate patients’ participation in clinical programs & identify opportunities member participation
- Define gaps in Humana’s service relationship with providers and facilitate resolution
- Identify specific practice needs where Humana can provide support
- Develop, enhance and maintain provider clinical relationship across product lines.
- Establish and foster a healthy working relationship between practice and Humana.
- Partner with physicians/physician staff to find ways to explore new ways to encourage member clinical participation in wellness and education.
- Provide resources and educational opportunities to provider and staff.
- Capture concerns/issues in action plans as agreed upon by Provider
- Document action plans and details of visits and outcomes
- Look beyond metrics to identify underlying issues that contribute to gaps.
- Prioritize Analyst work for specific reporting.
- Accountable for Provider Prioritization & communication of priorities to team.
- Assess data, identify opportunities, and understand how the team drives successful Triple Aim outcomes
- An active RN license in the designated state
- Strong interpersonal & relationship building skills
- Strong influencing, listening, and consultative skills
- Strong analytical skills, able to manipulate and interpret data
- Understanding of clinical programs
- Organizational and prioritization skills
- This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
- Bachelor’s degree in a related field
- CMS Stars/performance measures/HEDIS knowledge and/or experience
- Proven leadership experience
- Experience in a state and/or federally regulated health care environment
- Strong business acumen to help drive metrics
- Utilization management knowledge and/or experience
- Provider and member rewards program knowledge and experience
- This role reports to a Manager.
Scheduled Weekly Hours40