Role Scope
Transitions:Caretransition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient,observationand emergency department patients.
Quality: Medicare Advantage Stars, HEDIS and quality performance across value-basedpopulation.
Population Health: Deliver culturallyappropriate chronicdisease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD.
Duties and Responsibilities:
Analyze clinical data and trends from platforms such as Athena EMR andDataHubtoidentifygaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.
Proactivelyidentifyrecently discharged inpatient, observation and emergency department patients and coordinatetimelypost-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes ofutilizationand supporting patients to prevent avoidable readmissions or return visits.
Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management.
Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence.Identifyand escalate barriers, collaborating with providers and careteamto prevent readmissions and avoidable EDutilization.
Collaborate effectively with interdisciplinaryteams,including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff—to implement evidence-based interventions andoptimizeworkflows.
Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.
Prepare,participateand discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.
Participatein quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.
Monitorprogress toward Stars and Transitional Care Management goals, proactivelyidentifybarriers, and help develop innovative solutions to improve clinical performance and patient engagement.
Support clinic operations through provider collaboration, care coordination, and community education initiatives.
Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.
Maintainpatient confidentialityin accordance withHIPAA.
Document patient encounters accurately andtimelyin the indicated platform (e.g., medicalrecord).
Follow organizational policies related to safety, infection control, and attendance.
Perform other duties as assigned.
Required Qualifications:
Preferred Qualifications:
Additional Information
Core Competencies:
Values & Mission Alignment:
Work Information:
This role requires an in-center presence, involving daily commute to assigned clinic(s) and occasional (quarterly) travel within the market to alternative clinic(s) for strategic meetings.
TB Statement:
This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
Driving Statement:
This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.
Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$71,100 - $97,800 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
| Location | Las Vegas, Nevada |
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