Quality Improvement Nurse - New York City / Long Island

Role: Quality Improvement Nurse

Assignment: Sr. Segment

Location: NYC/Long Island Area – WAH/Field

This role requires regular travel (50-75%) within an assigned territory and the surrounding area. You must be local to this area.

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; we strive to ensure we provide perfect 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.

  • Review medical records and identify needed improvements that impact HEDIS measures or coding (i.e. identify deficiencies in data capture, use SQR to identify information and provide guidance to practice)
  • Deliver provider/member-specific metrics around profit and loss and coach providers on gap closing opportunities for Humana members
  • Facilitate regular Provider Engagement Strategy team meetings with ability to prioritize and interpret data through the use of strong analytical skills
  • Successfully promote practice-patients’ participation in clinical programs - providing information on participation, availability/descriptions and facilitating members with program engagement
  • Accurately define gaps in Humana’s service relationship with providers and facilitate resolution
  • Conduct outreach activities to members needing care and facilitating office visit scheduling with PCP, Specialists, etc.
Provider Concierge Responsibilities
  • Examine clinical programs information to identify members for specific Case Management / Chronic Care / Disease Management activities or interventions by utilizing established screening criteria
  • Monitor practice's patient participation as well as promoting Humana's clinical programs and resources
  • Facilitate member engagement
  • Identifies member quality/Hedis gaps and support gap closure by facilitating:
    • Follow up PCP visits
    • Specialist visits
    • Lab work
    • Prescription adherence
    • Chronic condition education
  • Consult with case managers and nurses to identify member specific opportunities
  • Identify Chronic Complex members not participating in Humana@Home and refer members to program
  • Consult with Manager/Clinical team on opportunities that need to be addressed in a Provider visit
  • Review member specific and provider specific data to identify concerns that need follow up by assigned Case Managers
  • Identify medication usage opportunities which require Pharmacy Consultant involvement
  • Coordinate and /or input specific representation into Strategy Meetings

Role Essentials

  • Clinical background - RN license required
  • Strong oral / written communication and presentation skills
  • Strong analytical skills, able to manipulate and interpret data
  • Office practice / hospital experience
  • Organizational and prioritization skills
  • Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 10Mx1M
  • This role is considered patient/provider 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

Role Desirables

  • Knowledge of HEDIS/Stars/CMS/Quality
  • Previous quality or process improvement experience in a hospital or physician office practice
  • Strong business skills, including sales and marketing objectives
  • Detail orientated and comfortable working with tight deadlines in a fast paced environment
  • Ability to work independently under general instructions, self-directed and motivated
  • Excellent PC skills
  • Travel with reliable transportation
  • CMS Stars/performance measures/HEDIS knowledge and experience
Reporting Relationships
  • You will report to the Provider Engagement Manager.
Additional Information

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn’t missed) inviting you to participate in a Montage Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.


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.

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.
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