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Description

Humana is a $77 billion (Fortune 41) market leader in integrated healthcare with a clearly defined purpose to help people achieve lifelong well-being. As a company focused on the health and well-being of the people we serve, Humana is committed to advancing the employment experience and vitality of the associate community. Through offerings anchored in a whole-person view of human well-being, Humana embraces a focus on stimulating positive individual and population changes while nurturing a sense of security, enabling people to live life fully and be their most productive. Against that backdrop, we are seeking an experienced healthcare leader to join our team as the Provider Reconciliation Program (PRP) Lead within the Healthcare Quality Reporting and Improvement (HQRI) organization. HQRI (comprised of Risk Adjustment and Health Quality & Stars) is responsible for improving health outcomes and advancing the care experience of our members and provider partners. The Risk Adjustment team collects and submits members’ health information to CMS for the purpose of accurately reporting the members health status, as well as inclusion in the appropriate clinical programs. The Health Quality and Stars team centralizes quality improvement and governance processes targeting Humana’s Medicare Advantage members while also managing compliant data submissions to CMS in adherence with the Stars Rating Program. The Provider Reconciliation Program (PRP) Lead promotes and improves the quality and measurement of care delivery programs within markets while working on problems of diverse scope and complexity ranging from moderate to substantial. The Provider Reconciliation Program (PRP) Lead works closely with technology, Stars and regional areas to support the program goals and strategies.

Responsibilities

The Provider Reconciliation Program (PRP) Lead engages and partners with physicians, physician groups, and regional leadership to drive initiatives. Influences and consults on matters related to quality and measurement of care delivery programs with a market(s), exercises independent judgment and decision making on complex issues regarding job duties and related tasks and works under minimal supervision using independent judgment on analysis of variable factors determining the best course of action.

  • Lead and develop a team of senior professionals
  • Manage provider inventory for the program to support HQRI strategies and sustainable program growth
  • Lead through substantial program changes including automation of program processes
  • Execute effective communications and strategies streamlining the information received by each region
  • Develop, maintain and strengthen relationships with both multiple areas across corporate and regional areas
  • Analyze divisional/regional data and employ improvement strategy utilizing partnerships with both Corporate and regional business areas
  • Develop a working knowledge of the company, its products, the healthcare industry and the regulatory agencies that govern us in order to develop messaging through effective communication channels

Required Qualifications

  • 2+ years leadership experience
  • 3+ years RA experience, either Corporate or regional
  • Claims processing experience/knowledge
  • Experience collaborating with legal, risk management, internal audit and compliance partners
  • Strong knowledge of Microsoft products
  • Excellent written and verbal communications skills
  • Proficiency in data analysis
  • Demonstrated process improvement experience
  • Ability to work/interact with all levels, including senior leadership, external partners and provider offices
  • Highly motivated, accountable and works with minimal direct supervision

Preferred Qualifications

  • Stars experience/knowledge
  • SQL experience/knowledge
  • Project management
  • Power BI experience
  • AAPC or AHIMA coding certification
  • EMR experience
  • Quality assurance experience
  • Degree in Healthcare Management, Healthcare Administration or related program
  • Experience working with external partner including providers and EMR vendors

Scheduled Weekly Hours

40



Request an Accommodation

If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this online application process and need an alternative method for applying, you may contact yourcareer@humana.com for assistance.

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Our Hiring Process

Apply online

To be considered for a job, you must apply online. Unfortunately, we cannot accept resumes that have been emailed to us. Once you find a job that interests you, simply select “Apply.” It typically takes 15 minutes to fill out the application form. Be sure to update your resume and upload it as you cannot edit the resume or add it after the application has been submitted. Shortly after you submit your application, you will receive a confirmation.

Next Step

If selected to continue with the interview process, you will be contacted through text or email to complete an assessment or schedule an initial live or recorded phone or video interview.

A hiring manager interview

After hiring managers and interview teams carefully consider the skills and experiences of applicants, they contact the top candidates via email or phone to schedule an interview.

Offer from Humana

If you’ve successfully completed the interview process and are identified as the candidate we would like to hire, you will receive an offer from our Talent Acquisition team.

Onboarding

If you accept the offer to join our Humana team, you will receive a welcome call or email to begin the onboarding process.


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Hiring Process