Quality Improvement - Critical Incident

Humana Illinois Market is seeking a Process Improvement Professional who analyzes and measures the effectiveness of existing business processes and develops sustainable, repeatable, and quantifiable business process improvements. This role focuses on oversight of Critical Incidents, a process recognized as a best practice by the Illinois Association of Medicaid Health Plans in 2024 and awarded their APEX award. The position requires interpretation of varied oversight requirements and independent determination of appropriate courses of action, with a strong understanding of department, segment, and organizational strategy.

Responsibilities

• Collaborate with Care Coordinators assigned to cases to determine strategies to mitigate further risk to members.
• Monitor Care Coordination activity and documentation regarding Critical Incidents.
• Collaborate with Leadership staff as needed regarding closure of Critical Incidents.
• Provide oversight for quarterly State audits of Critical Incidents.
• Provide reporting to the Illinois Quality Improvement Committee on Critical Incidents and support the Annual Quality report.
• Prepare monthly reports to the State regarding Critical Incidents.
• Provide training for new hires and current staff on updates to Critical Incidents.
• Perform audits focused on improving compliance and quality.
• Review new Critical Incident entries for appropriateness according to guidelines from Illinois oversight agencies.
• Develop and review internal quality metrics.
• Support process improvement initiatives.
• Assist in reviewing new Job Aids to support Learning Design and Learning Facilitation teams.
• Review current Job Aids and Policies and Procedures as requested.
• Create and present education as requested by the Process Improvement Manager.
• Participate in root cause analysis research for audits.
• Make decisions regarding own work methods, occasionally in ambiguous situations, with minimal direction.

Requirements

• Bachelor’s degree.
• 2 years of experience related to process improvement, compliance measures, or auditing practices or 2 years of experience in Medicaid/Medicare Care Coordination.
• Experience in Care Coaching and/or Care Coordination.
• Proven oral/written communication and presentation skills.
• Excellent analytical skills, able to manipulate and interpret data.

Preferred Qualifications

• Knowledge of Critical Incident reporting.
• Experience in Medicaid or Medicare Guidelines.
• Detail-oriented and comfortable working with tight deadlines in a fast-paced environment.

Schedule

• Core workdays: Monday – Friday.
• Typical hours: 8:00 AM – 5:00 PM Central Standard Time.
• Scheduled weekly hours: 40.

Workstyle

• Remote position with occasional travel to Humana’s offices for training or meetings.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
• Self-provided internet service must meet the following criteria:
  • Minimum download speed: 25 Mbps.
  • Minimum upload speed: 10 Mbps.
  • Wireless, wired cable, or DSL connection suggested.

Pay

The pay range for this full-time (40 hours per week) position is $65,000 - $88,600 per year. The range may vary based on geographic location, and individual pay will depend on demonstrated job-related skills, knowledge, experience, education, and certifications. This role is eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

Humana offers competitive benefits designed to support whole-person well-being, including:

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance.
• Additional opportunities for personal and professional growth.