Humana HEDIS Audit Clinical Advisor - RN in San Antonio, Texas

Role: HEDIS Audit Clinical Advisor - RN Assignment: Market Quality Operations Location: Work at home in any location

Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana’s Perfect Service® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.

Assignment Capsule Be a part of our Clinical Space – as a Clinical Advisor you will engage our members to develop lifelong wellbeing and health.

Humana is seeking a HEDIS Audit Clinical Advisor who will conduct clinical and compliance audits of HEDIS Supplemental and Hybrid Data for all lines of business to assure accuracy of external audit information submission. In this role you will be exhibiting the expert knowledge of Supplemental and Hybrid HEDIS information as it relates to the process of the internal and external audit program as well as for Stars Maximization. You will leverage your clinical knowledge and experience to accurately audit medical record reviews to assure the highest level of gap closure and passes.
* Enters data and processes information; retrieves assignment sheets, verifies information from medical records, enters information into database, documents as required, creates error letters and spread sheets as indicated.

  • Observes, receives, and otherwise obtains information from all relevant sources including but not limited to Verscend, OSQR, PMDM, MRM, and the HEDIS Share Point Site.

  • Provides information and ideas related to the audit process.

  • Alerts supervision of system issues and/or to trends and errors in reviewer data entry.

  • Establishes and maintains relationships via telephone, in written form, or in person.

  • Develops specific goals and plans to prioritize, organize, and accomplish responsibilities with or without supervisory guidance in a timely manner while meeting established production thresholds.

  • Analyzes information and evaluates results to choose the best solution and solve problems.

  • Keeps up-to-date with meetings, written information, and other updates; applies that information to established responsibilities.

  • Trains/Precepts other auditors as indicated.

    Role Essentials

  • Registered Nurse with an unrestricted license

  • 3-5 years’ or more of clinical and/or health plan experience

  • Familiar with Excel, Word, and pdf files

  • The Clinical Advisor must successfully pass all required HEDIS Chart Chase and Supplemental (OSQR) Measures and IRR Exams once hired

    Role Desirables

  • HEDIS experience

  • Clinical Audit experience

  • BSN or equivalent work experience Additional Information

    Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.

    Apply now, or join our Talent Network so you can stay informed and up to date on what’s happening at Humana.

Title: HEDIS Audit Clinical Advisor - RN

Location: KY-Louisville

Other Locations: US-Texas-San Antonio, US-IN-Indianapolis, US-FL-Tampa, US-WI-Green Bay

Requisition ID: 189319

Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.