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The Measure Optimization Lead - CC addresses complex business challenges affecting HEDIS Care Coordination measure performance. The role uses established reporting, operational knowledge, and input from internal and external partners to provide insights and recommendations to decision-makers. The Measure Optimization Lead works across initiatives of diverse scope and complexity, ranging from moderate to substantial.
The CMS Stars quality rating system evaluates Medicare Advantage and Prescription Drug Plans using approximately 40 measures covering preventive care screenings, health condition management, health outcomes, patient experience, and plan operations. In this pivotal role, you will provide HEDIS subject matter expertise and strategic leadership to advance Care Coordination measure performance. You will identify improvement opportunities, guide cross-functional initiatives, and translate approved reporting and analysis into clear recommendations for leadership. Your work will directly support decision-making and Stars improvement efforts that improve member care, strengthen plan quality, and advance organizational goals.
Key Responsibilities:
Strategic Leadership
- Lead the HEDIS Care Coordination measure optimization strategy and identify opportunities to improve performance.
- Evaluate business and operational factors affecting measure outcomes and recommend targeted improvements.
- Translate measure requirements, performance insights, and business needs into clear priorities and implementation plans.
Leadership Support
- Prepare high-quality materials and recommendations for vice presidents and senior leadership discussions.
- Participate in strategic conversations, providing actionable insights and clear recommendations.
- Communicate complex HEDIS, operational, and performance concepts in a clear and compelling manner to non-technical audiences.
Care Coordination Improvement Initiatives
- Collaborate with quality improvement, clinical, operations, technology, analytics, and vendor teams to assess and enhance Care Coordination measure performance.
- Lead initiatives from opportunity identification and business requirements through implementation and continuous improvement.
- Identify and resolve business and operational barriers affecting workflows, supplemental data pathways, source connectivity, and ownership.
- Act as a HEDIS subject matter expert, explaining measure requirements, methodology, and performance implications.
- Partner with analytics teams to frame business questions, interpret approved analyses, and translate findings into practical recommendations.
Business Reporting and Communication
- Define business reporting requirements and success measures for Care Coordination initiatives.
- Use established dashboards and reporting to communicate key metrics, trends, risks, and improvement opportunities.
- Promote accuracy, consistency, and clarity in business materials and executive communications.
Use your skills to make an impact Required Qualifications
- Bachelor’s degree
- 7 or more years of experience in data analysis and/or business intelligence
- 3 or more years of experience with Medicare Advantage, Stars programs, HEDIS measures, or healthcare quality improvement
- Strong understanding of CMS Star Ratings
- Experience with business intelligence tools such as Power BI, Tableau, Qlik, SQL, or similar platforms
- Experience defining business questions and requirements for analytical and technical partners
- Ability to interpret reporting and analytical findings, identify root causes and performance drivers, and translate insights into practical recommendations
- Proven ability to work across business, clinical, operational, technology, analytics, and vendor teams
- Experience leading complex initiatives, managing accountability, resolving issues, and influencing outcomes without direct authority
- Excellent communication and presentation skills, with the ability to convey complex concepts clearly to senior leadership
Preferred Qualifications
- Experience with Care Coordination measures, including Follow-Up After Emergency Department Visit, Transitions of Care, and Plan All-Cause Readmissions.
- Experience with payer claims data, clinical data, supplemental data, medical record review, or HEDIS audit support.
- Experience working with healthcare vendors and enterprise technology partners.
- Advanced degree in healthcare administration, public health, business, analytics, or a related discipline.
Additional Information
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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
- Employees 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 employees 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
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue 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.
Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from [email protected] with instructions on how to add the information into your official application on Humana’s secure website.
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.
$117,600 - $161,700 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
