Senior Quality Improvement Professional

** Become a part of our caring community*
* If you are passionate about Clinical Quality and enjoy being responsible for ensuring the company is prepared for audits that impact Humana's certification and accreditation status, this may be the role for you. The Senior Quality Improvement Professional implements quality improvement programs for all lines of business including annual program description, work plan, and annual evaluation. The Senior Quality Improvement Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Success in the Senior Quality Improvement Professional role will require:

** Clinical Skills and Knowledge*
* + Exhibits proficient knowledge of HEDIS Supplemental and Hybrid seasonal requirements and processes as they relate to the internal audit process.

+ Leverages clinical knowledge and experience to audit medical record reviews.

+ Ensures compliance with HEDIS Technical Specifications and provides feedback to improve reviewer quality and ensure all practices are consistent with external audit/NCQA requirements.

** Expanded Data and Quality Competencies*
* + Demonstrates understanding of end‑to‑end clinical data flows, including provider data submission (e.g., EHRs, HIEs/registries, remote monitoring), data mapping and normalization, vendor ingestion of CQL‑based measures, and automated return of results to health plan systems.

+ Proven ability to interpret, validate, and troubleshoot CQL‑based clinical quality measure logic to ensure accurate implementation and measurement across data sources and platforms.

+ Strong expertise in validating data lineage and traceability, including mapping accuracy and integrity from source through all stages of transformation and use.

+ Experience validating not only primary source verification (PSV) but also upstream and downstream data pipelines to ensure data accuracy, consistency, and reliability throughout the data lifecycle.

+ Working knowledge of evolving NCQA requirements for electronic clinical data systems, digital measures, and CQL, with the ability to adapt audit and validation approaches accordingly.

+ Foundational understanding of SQL desired, including the ability to read, interpret, and validate existing queries.

** Execution for Results*
* + Leverages resources to create exceptional outcomes, driving quality improvement of nurse reviewer KPIs and ensuring the integrity of HEDIS data through all stages of transformation and utilization.

** Pursuit of Excellence*
* + Seeks growth opportunities from available resources.

+ Exhibits ample focus, attention to detail, reliability, and flexibility to reprioritize work as needed to drive outcomes.

** Organization*
* + Demonstrates agility and adaptability in an environment of frequent organizational change.

+ Contributes to feedback loop with audit leadership and team - communicating pertinent information related to reviewer errors and error trending, as well as stakeholders involved in HEDIS data ingestion, transformation, and utilization.

** Accountability*
* ** Meets role expectations and takes responsibility for actions, utilizing result of actions as learning and growth opportunities.*
* ** Job

Activities:

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* Computer/Data Systems

+ Utilize role-specific technological tools and applications to collect, interpret, and process data.

+ Verifies conformity between member information and measure data in medical records, HEDIS Technical Specifications, Humana systems, and pseudo-claim/gap data entered by nurse reviewers.

+ Enters/documents all audit findings into Power Apps-based audit data entry system and Rapid Retrieve annotations.

+ Generates and distributes error notifications as needed to provide reviewer redirection/opportunity for course correction, thereby reducing risk of further errors.

+ Validates integrity of data pipelines to ensure accuracy, consistency, and integrity throughout the lifecycle.

Obtaining/Utilizing Key Data

** Obtain and/or enter relevant data utilizing the following systems and resources:
Cotiviti Rapid Retrieve, Quality Reporter Web, OSQR/PPI, PMDM, MRM, MS One Note,…