**Become a part of our caring community and help us put health first** The Process Improvement Lead researches best business practices within and outside the organization to establish benchmark data. Collects and analyzes process data to initiate, develop and recommend business practices and procedures that focus on enhanced safety, increased productivity and reduced cost. Determines how new information technologies can support re-engineering business processes. May specialize in one or more of the following areas: benchmarking, business process analysis and re-engineering, change management and measurement, and/or process-driven systems requirements. Advise executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action. **JOB SUMMARY** The Process Improvement Lead analyzes and measures the effectiveness of existing business processes and develops sustainable, repeatable and quantifiable business process improvements. The Process Improvement Lead works on problems of diverse scope and complexity ranging from moderate to substantial. **KEY ACCOUNTABILITIES** 20% 1. Maintain current knowledge of the TRICARE program through involvement in day-to-day UM activities and discussions with UM leaders. 20% 2. Review and monitor Contract Change Orders and evaluate impact on Utilization Management processes. Organize and facilitate Change Order workgroup and maintain documentation for implementation task completion. 15% 3. Collaborate with UM leaders and clinicians to identify opportunities to implement electronic prior authorization technology, implement software rules to deploy the technology, and communicate with leaders throughout the process. 15% 4. Collaborate with UM leaders to develop process mapping for operational processes and offer recommendations for optimization and/or improvements. 15% 5. Assist with research, development and submission of quarterly evolving practices report in collaboration with other UM associates and Medical Directors 10% 6. Create and maintain department communications in the form of monthly/quarterly newsletters, SharePoint site maintenance and support, or other forms of team communications as needed. 5% 7. Other duties as identified by UM leaders that support and optimize operational processes, which may include assisting with policies & procedures, UM reaccreditation readiness, system testing. PROCESS IMPROVEMENT LEAD Detail-oriented individuals are essential when streamlining and perfecting the operating models of a successful company. The Process Improvement Lead contributes to the success of Humana's business strategy by continuously reevaluating existing work processes in order to predict, address and resolve issues of noncompliance while delivering Humana's trademark innovative products and services to consumers. **Business Acumen** Understands how one’s role and team add value for customers. Understands how the various parts of Humana work together to turn our strategy into reality and ultimately make Humana competitive in the marketplace. Acts in accordance with Humana's ethics and compliance policies and connects industry and regulatory changes to our strategy. Articulates how Humana's value proposition differentiates us. **Company policies & procedures** Is knowledgeable of the internal and external regulations that influence the company's position and established policies. Applies that knowledge to assessing, developing, and/or infusing policies and procedures with business operations. **Compliance** Understands the federal and state regulatory environment in relation to insurance and business practices. Understands the requirements for developing, implementing and enforcing compliance programs. **Consultation** Balances business knowledge, an area of expertise, and a system-wide view to create successful outcomes for all parties. Leads partnerships by listening, clarifying scope, ascertaining root cause, prioritizing key deliverables, and defining success. Uses information, communication, and influence to implement recommendations that add value to Humana's overall success. **Accountability** Meets established expectations and takes responsibility for achieving results; encourages others to do the same. Employees focus, attention to detail, reliability, and appropriate prioritization to drive outcomes. Sees opportunities to contribute and takes the initiative to create solutions. **Collaborates** Engages others by gathering multiple views and being open to diverse perspectives, focusing on a shared purpose that puts Humana's overall success first. Develops and strengthens networks and relationships, both inside and outside the organization, that support company performance. Proactively and transparently contributes information and energy toward creating value with others. **Customer Focus** Connects meaningfully with customers to build emotional engagement and customer advocacy. Develops and applies deep customer knowledge and intimacy to develop and deliver products, services, and interactions that provide value beyond expectations. Simplifies complexity and integrates internal efforts to deliver an optimal customer experience. **Interpersonal Effectiveness** Understands oneself, effectively manages emotions, and displays awareness of how one's actions affect others. Listens and communicates with respect and empathy toward others. Builds trusting relationships through accountability and integrity in actions. **Leads Change** Models agility, adaptability and an openness to new ways of thinking and operating. Guides and energizes others to embrace new opportunities arising from change. Inspires strong organizational performance through periods of transformation, ambiguity, and complexity. **Leads Positively** Leads by example to cultivate a climate of motivation, positive energy and meaning in work. Empowers and guides associates to take personal responsibility, encouraging them to productively learn, flourish, and strengthen team capacity. Assesses, selects, recognizes, and develops diverse talent to capitalize on competencies, ideas and passions. **Use your skills to make an impact** **Required Qualifications** + **Registered Nurse (R.N.)** **with current, unrestricted licensure** + BSN or degree in related medical field + Minimum of 5 years experience utilizing medical necessity review criteria (E.G. MCG, InterQual) + **Our Department of Defense Contract requires U.S. citizenship for this position** + **Successfully receive approval for government security clearance (Via National Background Investigation Services NBIS)** **HGB is not authorized to do work in Puerto Rico per our government contract.** + **We are not able to hire candidates that are currently living in Puerto Rico** **Preferred Qualifications** + Certification in managed care nursing + Experience utilizing access databases and data visualization software such as Tableau or Power BI + Knowledge of medical coding to include ICD-10, CPT, HCPCS + Knowledge of medical claims processing procedures + Extensive analytical skills + Experience with process mapping utilizing Visio or other software + ·Six Sigma/Lean Certification + Project Management Professional (PMP) Certification **Additional Information** **Work Style** : Remote **Work at Home/Remote Requirements** To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home 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 and computer 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 **ALERT** : Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana’s secure website. Interview Format: As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making. If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes. If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews. This is a remote position \#LI-Remote 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. $94,900 - $130,500 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. **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.