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Participate in Quality Operations including Quality Management Committee, monitor initial peer review on quality of care complaintsParticipate in National, Regional and local meetings of organizations of interest to Group MedicareSpeaking engagements to provide thought leadership on behalf of Humana Group MedicareOversee quality improvement and HEDIS/STARS metrics to improvement with corporate and local market resources.
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One (1) year experience translating regulatory requirements such as HEDIS, CAHPS, TJC to KP operations and data. Knowledge, Skills, and Abilities (KSAs): Health Care Data Analytics; Reporting Tools; Analytical Software Tools; SAS Tools; Written Communication; Data Extraction; Data Mining; Data Visualization Tools; Statistical Programming Language; Relational Database Management; Project Management; Business Planning.
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Managed care experience including knowledge of HEDIS and CMS guidelines preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) or willingness to obtain certification within a specified time.
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Utilizes extensive HEDIS and coding knowledge, combined with medical policy, credentialing, and contracting rules knowledge to help build the effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality outcomes and STARs outcomes while not compromising payment integrity.
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Develop programs to improve HEDIS scores. The Wellness Nurse Consultant position is responsible for developing and recommending customized, group-specific strategies to improve the health and wellness of the federal employee, leveraging company and FEP programs and resources as well as industry best practices.
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Assist with network development and provider contracting with various providers and ancillary providers. The CMO Group Medicare will be an integral part of the GM Leadership team and will be responsible to lead and provide thought leadership internally and externally on behalf of Group Medicare.
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Ensure accurate documentation in the electronic health record (EHR) and electronic medical record (EMR) systems, including documentation of HEDIS and Stars quality measures. Experience with HEDIS and ICD/CPT coding.
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The CMO Group Medicare will provide medical leadership and strategy for the GM business. The CMO Group Medicare, requires and in-depth understanding of how organization capabilities interrelate across segments and/or enterprise-wide.
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Gap Closure for HEDIS and other contracted quality measures: Identify care gaps through analysis of patient data, electronic health records (EHRs), and quality performance metrics. Minimum of five years of experience in a clinical healthcare setting, preferably in ambulatory care or primary care Strong understanding of preventive care guidelines, quality improvement initiatives, and value-based care principles.
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Attend current/future client meetings to deliver insights re: Humana clinical model of care and other programs designed to positively impact overall member health. Work with local market utilization management and case management teams for inpatient cases.
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A current and unrestricted license in at least one jurisdiction and willing to obtain licensePhysician (MD/DO), Nurse Practitioner, Physician Assistant, Registered NurseExcellent communication and presentation skills5 years of established clinical experience.
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Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products. The Chief Medical Officer, Group Medicare relies on the medical background to create and oversee clinical strategy for the Group Medicare business.
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Work collaboratively with account and sales teams to deliver our superior clinical experience story to all our audiences. Provide guidance for the implementation of regional clinical programs and strategies, as well as, developing and implementing national strategies overall and for individual clients.
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Ability to thrive in a matrix environment. Well versed on financial aspect of various levels of risk bearing contracts. Must be passionate about contributing to an organization focused on continuously improving consumer experiences.
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Scheduled Weekly Hours.
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hedis job
FEATURED BLOG POSTS
Virtual Reality Job Interviews
With the advent of desktop computers, the arduous task of scouring through weekly job classifieds became a thing of the past. The mid-1990s brought about a new era where job seekers could easily search and apply for jobs online. The introduction of AOL's Instant Messaging feature provided an even faster means for employers and candidates to communicate and schedule interviews. As smartphones became more pervasive in the early 2000s, hiring managers increasingly used phone calls for screening and interviewing candidates. Despite this trend, over 80% of interviews still took place in person.
A Potential TikTok Ban?!
As you may already know, there has been a lot of talk lately about the possibility of a TikTok ban. While this has not yet come to fruition, it's important to consider the implications this could have for businesses and recruiters who rely on TikTok as a platform to market their brand, recruit new talent, and connect with their audience.
The Effects of Workplace Racism and Sexism
One day it's a covert statement to a mother returning to work after maternity leave. Another day it's a lingering gaze at an employee enjoying a culturally rich meal. These microaggressions (or sometimes macroaggressions) can take an employee from a confident, high-performer to one that feels insecure being themselves at work. Your employees engage with people with different ideas and feel most comfortable and valued when they can work without losing their cultural, racial, and gender identity. While most employers know this, why have workplace racism and sexism often been neglected?
When Rage Applying Strikes: How to Identify Unserious Candidates
As the job market remains highly competitive, we have seen a surge in "rage applying." This is when candidates apply to multiple jobs, often without considering whether they are truly interested in the role. Rage applying goes hand-in-hand with quiet quitting. Often, employees want to entertain the thoughts and feelings of leaving their job, but they aren't necessarily serious about leaving yet. Meanwhile, other employees engaging in this trend are actually trying to find a better role. As a recruiter, it can be hard to identify who are the real applicants in a sea full of quiet quitters, but understanding rage applying and identifying red flags will certainly help.
How to Increase Job Ad Exposure
In today's competitive job market, writing quality job ads is critical for attracting top talent to your organization. While networking and candidate referrals are prime real estate for finding qualified candidates, nothing beats the tried-and-true method of writing an extraordinary job ad. But while writing a great job ad is the first step, what's more important is increasing visibility. You could have the most detailed, well-written ad on the internet, but if no one sees it, then you are wasting time (and potentially money!). Employers often believe that job boards are the root of the problem, but you can learn how to increase job ad exposure by tweaking a few steps of your recruitment process.
How to Navigate Hiring Out of State
The job market has shifted significantly in recent years. The accelerated adoption of technology has not only pushed many companies into remote working arrangements but also increased the availability of supporting tools and technologies (i.e., video conferencing and collaboration software).
Building a Candidate Pipeline Through Internships
Building a candidate pipeline through a great internship program for local college students and recent graduates at local universities is a great and cost-effective way to attract and retain top talent. By offering meaningful and impactful work experiences, regular feedback, coaching, and mentorship, you can create a positive internship experience that will make your organization a sought-after destination for future employees. This not only benefits the organization in the short-term but also in the long-term, as you'll have a pool of well-trained and experienced candidates who may be interested in full-time employment once they graduate. Furthermore, building relationships with local universities and college students can increase brand awareness and build a positive reputation for your organization in the local community.