In Home Eligibility Lead

📋 Description

• • Oversee and manage eligibility strategy, execution, and data integrity for in-home Quality Focused Visits (QFV) and related In-Home Wellness Assessment (IHWA) vendor programs.
• • Ensure accurate member targeting, consistent eligibility logic, and timely delivery of eligibility files across multiple external vendor partners.
• • Design, maintain, and refine eligibility criteria to minimize program overlap, reduce operational risk, and support Stars quality metric outcomes.
• • Translate program and quality requirements into executable eligibility rules, automated data processes, and scalable file delivery systems.
• • Partner cross-functionally with IHWA operations, Stars teams, analytics, IT, and external vendors to align eligibility workflows with business and regulatory goals.
• • Analyze complex data sets including eligibility files, member lists, and disposition data to identify risks, inconsistencies, gaps, and opportunities for process improvement.
• • Drive the transition from manual eligibility processes to automated, scalable solutions to support program growth and evolving business needs.
• • Proactively identify and resolve eligibility-related risks that could impact member access, vendor performance, or quality reporting outcomes.
• • Communicate complex eligibility logic and data requirements clearly to both technical and non-technical stakeholders across departments.
• • Manage multiple priorities and deadlines in a fast-paced, high-visibility environment with a focus on accuracy and compliance.
• • Maintain data governance standards and ensure audit readiness for all eligibility-related processes and documentation.
• • Support vendor governance by monitoring performance, ensuring contract compliance, and aligning eligibility outputs with vendor capabilities.
• • Contribute to the development of prioritization rules, exclusion criteria, and eligibility logic that optimize member coverage and operational efficiency.
• • Ensure all remote work activities comply with HIPAA requirements by working from a dedicated, interruption-free space that protects member PHI.
• • Participate in occasional travel to Humana offices for training, meetings, or program alignment sessions as required.