Humana Clinical Quality Manager in San Antonio, Texas

Role:Clinical Quality Manager

Assignment: Humana Government Business- Quality Review/Behavioral Health

Location:Louisville, KY/San Antonio, TX/ WAH

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

The Clinical Quality Manager for Humana Government Business provides executive leadership for region-wide clinical quality management (CQM) activities. Has overall responsibility for implementing the Clinical Quality Management Program plan in the 10-state South Region. Exercises broad oversight and collaborates with various key staff to ensure the integration of quality functions performed in field operations. Serves as the regional liaison with the Tricare Regional Office and with the corporate office.

Our Department of Defense Contract requires U.S. citizenship for this position.

  • Manages the analysis, determination, and disposition of clinical quality reviews. Ensures there is consistency in processing potential quality issues and that CQM contract requirements and standards are met. Monitors cases entered in the Clinical Quality Management Data System for accuracy, completeness, clarity, and timeliness.

  • Directs all regional CQM activities. Coordinates with associates in field operations to ensure identification and resolution of clinical quality issues and improvement opportunities. Administers all Patient Safety Peer Review Committee proceedings, including the agenda, case presentations, data collection and summary reports and other associated functions. Keeps leadership informed of public policies, DoD regulations and guidance, and legislative and health care trends that affect CQM. Ensures field compliance with accreditation standards relating to CQM.

  • Supervises QM coordinators. Implements improvement plans as necessary. Provides education, training, consultation, and support necessary to ensure successful performance

Role Essentials

  • Bachelor’s Degree in Nursing

  • Registered Nurse with current in-state RN license

  • Minimum 2 years quality management experience within past 5 years

  • Previous supervisory experience

  • Expertise in data management, statistical analysis, and reporting

  • Strong written and verbal communications skills

  • Excellent organizational skills and attention to detail

  • Computer skills that include basic Word, PowerPoint, and Excel

Role Desirables

  • Certification in a recognized professional UM/QM organization. (i.e., CPHQ)

  • Current experience with regulatory agency guidelines and regulations such as TJC, URAC, CMS, and NCQA

  • Master’s Degree

  • Proficiency in project management

Additional Information

At Humana, we know your well-being is important to you, and it’s important to us too. That’s why we’re committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. If you share our passion for helping people, we likely have the right place for you at Humana.

Job Clinical Innovations and Health Practitioners

Title: Clinical Quality Manager

Location: Texas-San Antonio

Requisition ID: 167533