UNKNOWN

ADAPTED_NOW

The Supervisor, Provider Engagement represents the scope of health plan/provider relationship across such areas as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation and coding, HEDIS and STARs performance, operational improvements and other areas as they relate to provider performance, member experience, market growth, provider experience and operational excellence. To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.

YEAR

Become a part of our caring community and help us put health first The Supervisor, Provider Engagement develops and grows positive, long-term relationships with physicians, providers and healthcare systems in order to support and improve financial and quality performance within the contracted working relationship with the health plan. The Supervisor, Provider Engagement works within thorough, prescribed guidelines and procedures; uses independent judgment requiring analysis of variable factors to solve basic problems; collaborates with management and top professionals/specialists in selection of methods, techniques, and analytical approach. The Supervisor, Provider Engagement represents the scope of health plan/provider relationship across such areas as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation and coding, HEDIS and STARs performance, operational improvements and other areas as they relate to provider performance, member experience, market growth, provider experience and operational excellence. Decisions are typically are related to schedule, plans and daily operations. Performs escalated or more complex work of a similar nature, and supervises a group of typically support and technical associates; coordinates and provides day-to-day oversight to associates. Ensures consistency in execution across team. Holds team members accountable for following established policies. Use your skills to make an impact Required Qualifications + Bachelor's Degree or minimum of 5 yrs of supervisory experience in the dental industry + 4 or more years of Health care or managed care with Provider Contracting, Network Management or Provider Relations experience + 2 or more years of prior supervisory experience in a fast paced operational setting; driven by quality metrics + Proven planning, preparation and presenting skills, with established knowledge of reimbursement and bonus methodologies + Demonstrated ability to manage multiple projects and meet deadlines + Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications + Master's Degree + Proficiency in analyzing and interpreting financial trends for health care costs, administrative expenses and quality/bonus performance + Comprehensive knowledge of Medicare policies, processes and procedures Additional Information To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested + Satellite, cellular and microwave connection can be used only if approved by leadership + Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. + Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. + Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay 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. $78,400 - $107,800 per year This 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 10-05-2025 About us Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. ​ 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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Humana

Supervisor, Provider Engagement

FULL_TIME

FEED

OTHER

The team lead supports clinical and non-clinical staff supporting CQM programs by providing training and onboarding of new staff; determining work assignments; performing audits for clinical records and/or work accuracy; and ensuring effective, consistent and accurate workflow. Technical Skills: Comprehensive knowledge of research methodology; proficient applying appropriate data analysis processes; knowledge of managed care principles and methods; knowledge in the application of clinical criteria; proficient with Microsoft Word, Excel, and PowerPoint.

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.Veterans, Reservists, Guardsmen and military family members are encouraged to apply!Job Summary The position is responsible for supporting Clinical Quality Management (CQM) staff production and quality processes; assisting in the development of policies and procedures related to CQM; meeting CQM contractual requirements focused on TRICARE Quality Monitoring Contract (TQMC) requirements and ensuring compliance with URAC standards. The team lead supports clinical and non-clinical staff supporting CQM programs by providing training and onboarding of new staff; determining work assignments; performing audits for clinical records and/or work accuracy; and ensuring effective, consistent and accurate workflow. The position also assists the Supervisor and Manager in developing study topics, quality improvement processes and reporting in support of the CQM program.Education & Experience Required: • RN or LCSW (Independently Licensed Clinical Social Worker) with current unrestricted license in appropriate state or territory of the United States • If supporting TRICARE contract, must be a U.S. Citizen • If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation • 5+ years of clinical experience in a variety of settings (behavioral health and medical/surgical) • 2 years of team lead experience • 1+ year of experience in Quality Management to include conducting medical records abstracting and quality investigations Preferred: • Bachelor's degree in Nursing Health Administration, health-related field or equivalent and experience • Certified Professional in Healthcare Quality (CPHQ) • General knowledge of nationally recognized standards of care, Interqual, CMS, HEDIS, AHRQ, TRICARE, or government health care programs • General knowledge of Medicare, TRICARE, or government health care programsKey Responsibilities • Provides support to Clinical Quality clinical and non-clinical daily operations and ensures timeliness and accuracy of work to meet all contract requirements, particularly those related to TQMC. • Assists the supervisor in assigning cases appropriately according to clinicians' scope of practice. • Monitors and ensures appropriate and accurate focused study data collection, analysis, and reporting. • Provides input regarding training modules on quality management basics for teaching staff. • Trains and mentors Clinical Quality staff. • Identifies, develops, and monitors focused reviews and other quality studies. Keeps Supervisor informed of issues related to quality studies and PQIs. • Provides accurate communications on case reviews. • Performs staff audits and develops summary reports. • Ensures adherence to accreditation standards, TRICARE policy, contractual requirements and nationally recognized practice standards. • Participates in working case review meetings. • Conducts Potential Quality Issue (PQI) investigations by performing a timely and complete case analysis. Maintains a consistent PQI caseload of 2 - 5 cases. • Requests query reports, as appropriate, and analyze data supporting focused reviews and quality studies. • Refers cases to supervisor for review as appropriate to and from Program Integrity, Case Management, Provider Services, Congressional and Customer Relations, and other TriWest departments. • Supports TriWest committees as a representative of Clinical Quality Management. • Performs other duties as assigned. • Regular and reliable attendance is required.Competencies Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback. Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate. Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications. Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented. Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Comprehensive knowledge of research methodology; proficient applying appropriate data analysis processes; knowledge of managed care principles and methods; knowledge in the application of clinical criteria; proficient with Microsoft Word, Excel, and PowerPoint.Working Conditions Working Conditions: • Telecommute with minimal travel • Ability to use a computer and sit for prolonged periodsCompany Overview Taking Care of Our Nation's Heroes. It's Who We Are. It's What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®! Our job is to make sure that America's heroes get connected to health care in the community. At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.DoD StatementOur Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.BenefitsWe're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes: <ul><li> Medical, Dental and Vision Coverage </li><li> Paid time off </li><li> 401(k) Retirement Savings Plan (with matching) </li><li> Short-term and long-term disability, basic life, and accidental death and dismemberment insurance </li><li> Tuition reimbursement </li><li> Paid volunteer time </li></ul> TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $90,000 - $101,000 per year.Equal Employment OpportunityTriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.

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TriWest Healthcare Alliance

Clinical Quality Review Team Lead

equestftpin

The RN assesses patient/family needs, develops and priorities patient goals, evaluates care delivery, and continually revises the plan of care to meet the biological, emotional, psychosocial, spiritual, developmental, and educational needs of the patient/family. The University of Kansas Health System St. Francis Campus, a part of a rich legacy of compassionate care since 1909, now offers 378 licensed beds, a history of innovation, and strong community support.

Overview:
Join our team as a day shift, full-time, Clinical Decision Unit Charge Registered Nurse in Topeka Kansas. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better<ul><li>Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being.</li><li>People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for.</li><li>Make Healthcare Better: We use advanced technology to support our team and enhance patient care.</li></ul>Get to Know Your Team:<ul><li>The University of Kansas Health System St. Francis Campus, a part of a rich legacy of compassionate care since 1909, now offers 378 licensed beds, a history of innovation, and strong community support.</li></ul>Learn About A Day in the Life of a Med-Surg RN: <div></div>

Responsibilities:
<ul><li>Under the direction of the Nurse Manager, is responsible for the overall shift management and monitoring of the quality of care for his/her designated area. </li><li>The Charge RN serves as a liaison to keep the Nurse Manager and House Supervisor apprised of major occurrences and needs of the unit.  Provides first level supervision, makes patient assignment every shift and provides clinical support to nursing personnel (e.g. assuming patient load, assisting with admissions/procedures, etc.) and problem identification/solving of patient care issues.</li><li>The Charge Nurse assists in mentoring of new associates, academic partners and participates in annual performance review process. Performs other duties as assigned.</li><li>The RN assesses patient/family needs, develops and priorities patient goals, evaluates care delivery, and continually revises the plan of care to meet the biological, emotional, psychosocial, spiritual, developmental, and educational needs of the patient/family. </li><li>The RN delegates care as appropriate to optimize patient outcomes. </li><li>The RN adheres to the Kansas Nurse Practice Act.</li></ul>

Qualifications:
Job Requirements:<ul><li style="margin:2pt 0in 0in 0px;text-align:justify;font-size:11pt;font-family:'calibri' , sans-serif">2-year degree</li><li style="margin:2pt 0in 0in 0px;text-align:justify;font-size:11pt;font-family:'calibri' , sans-serif">Current Kansas RN licensure.</li><li style="margin:2pt 0in 0in 0px;text-align:justify;font-size:11pt;font-family:'calibri' , sans-serif">Basic Life Support (BLS) certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care.</li><li style="margin:2pt 0in 0in 0px;text-align:justify;font-size:11pt;font-family:'calibri' , sans-serif">Advanced Cardiovascular Life Support (ACLS) certification - unit specific.</li></ul>Preferred Job Requirements:<ul><li style="margin:2pt 0in 0in 0px;text-align:justify;font-size:11pt;font-family:'calibri' , sans-serif">4-year degree</li><li style="margin:2pt 0in 0in 0px;text-align:justify;font-size:11pt;font-family:'calibri' , sans-serif">Preference given to RNs with experience in a similar healthcare setting</li></ul>

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Supervisor, Provider EngagementHumana

Clinical Quality Review Team LeadTriWest Healthcare Alliance

Charge Registered Nurse / RN Clinical Decision UnitThe University of Kansas Health System St. Francis Campus

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