Human Evaluator in United States

Become a part of our caring community The Field Care Manager Nurse 2 assesses and evaluates member's needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. You will report to the Manager, Care Management of Behavioral Health. The Field Care Manager Nurse 2 employs a variety of strategies, approaches, and techniques to manage a member's physical, environmental, and psycho-social health issues. Identifies and resolves barriers that hinder effective care. Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations. May create member care plans. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. In this role, you will travel up to 50% of the time to support collaboration, conduct face-to-face meetings, and engage directly with staff, providers, members, and their families. NOTE: You should reside close to the Midlands OR Upstate area where your region will be. Use your skills to make an impact Required Qualifications Bachelor's in nursing (BSN) and have an active license in the state of South Carolina without disciplinary action. Must reside in the State of South Carolina 2 or more years of experience of case/care management 2 or more years working with the behavioral health population Knowledge of community health and social service agencies and additional community resources Use a variety of electronic information applications/software programs including electronic medical recor

Become a part of our caring community The Field Service Coordinator (Care Coach 1) assesses and evaluates member's needs and requirements. This is done to achieve and/or maintain optimal wellness state by guiding members/families toward resources appropriate for their care and wellbeing. The Service Coordinator work assignments are often straightforward and of moderate complexity. Your role will involve meeting members in their location, spending quality time assessing their needs and barriers and then connecting our members with quality services to promote their ultimate well-being and guide health outcomes. Responsibilities include: Administer ongoing long-term services and support (LTSS) related assessments through person-centered thinking approaches. Contacts members both telephonically and/or in-person to establish goals and priorities. This involves evaluating resources, developing a plan of care, and identifying LTSS providers and community partnerships. The goal is to provide a combination of services and supports that best meet the needs and goals of the member and caregiver through person-centered thinking approaches. Development and modification of Service Plan and involve applicable members of the care team in care planning (Informal caregiver coach, PCP) Support members through navigation of their LTSS and related environmental and social needs Use available information about member to prevent the need for administration of duplicative assessments. Focus on supporting members or caregivers in accessing long-term services and support, social, housing, educational and other services, regardless of funding sources to meet their needs. Assist members in maintaining Medicaid eligibility Collaborate with Medical Director/Geriatrician/Care Coordinator as deemed necessary to ensure cohesive, holist

Become a part of our caring community The Field Care Manager Nurse 2 assesses and evaluates member's needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. You will report to the Manager, Care Management of Behavioral Health. The Field Care Manager Nurse 2 employs a variety of strategies, approaches, and techniques to manage a member's physical, environmental, and psycho-social health issues. Identifies and resolves barriers that hinder effective care. Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations. May create member care plans. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. In this role, you will travel up to 50% of the time to support collaboration, conduct face-to-face meetings, and engage directly with staff, providers, members, and their families. Note: travel requirements have shifted and you will only need to travel up to 50%. Also, one of the questions within the application relate to travel and can't be adjusted to reflect the change. NOTE: You should reside in the Midlands OR Upstate area where your region will be. Use your skills to make an impact Required Qualifications Bachelor's in nursing (BSN) and have an active license in the state of South Carolina without disciplinary action. Must reside in the State of South Carolina 2 or more years of experience of case/care management 2 or more years working with the behavioral hea

Become a part of our caring community The Senior Software Engineer codes software applications based on business requirements. The Senior Software Engineer work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior Software Engineer standardizes the quality assurance procedure for software. Oversees testing and debugging and develops fixes. Researches complaints and makes necessary adjustments and/or recommendations to resolve complex software related issues. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and performs work without direction. Exercises considerable latitude in determining objectives and approaches to assignments. Collaborates with Business partners and Solution and Application architects in designing software solutions Use your skills to make an impact Required Qualifications Bachelor's Degree in Computer Science or related field 5 or more years of experience designing, developing, and testing of software applications and/or infrastructure Must be passionate about contributing to an organization focused on continuously improving consumer experiences 5+ years’ experience with Workday integration techniques including RaaS, API, Cloud Connector, and EIB 4+ years’ experience collaborating with HR, Talent, Payroll, Benefits, and Learning teams 3+ years’ experience with Workday architecture and data structures 3+ years’ experience working with protected information 2+ years’ experience implementing Workday security including SSO and MFA Preferred Qualifications Master's

Become a part of our caring community The Care Manager, Telephonic Behavioral Health 2 , in a telephonic environment, assesses and evaluates members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. The Care Manager, Telephonic Behavioral Health 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Care Manager, Telephonic Behavioral Health 2 employs a variety of strategies, approaches and techniques to manage a member's physical, environmental and psycho-social health issues. Identifies and resolves barriers that hinder effective care. Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations. May create member care plans. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. Reports to the Regional CM Manager. Use your skills to make an impact Required Qualifications Must have an active, unrestricted SC Licensed Masters Social Worker (LMSW), Licensed Professional Counselor (LPC) OR an active, unrestricted compact Registered Nurse (RN) license . 2 or more years of experience working as a behavior

Become a part of our caring community The Telephonic Quality Outreach Professional supports the EPSDT program requirements in a telephonic outreach environment by evaluating member needs and helping families achieve or maintain an optimal state of wellness. The Telephonic Outreach Care Coach Professional 1 performs basic administrative/clerical/operational/customer support/computational tasks. Typically work on straightforward moderate complexity assignments that are routine and structured in nature. The Telephonic Quality Outreach Professional employs a variety of strategies and techniques to coordinate services and resources that facilitate HEDIS gap closure and improve pediatric health outcomes. The supervisor limits decisions to defined parameters around work expectations, quality standards, priorities and timing, and supervises closely and/or works within established policies/practices and guidelines with minimal opportunity for deviation. Position Responsibilities: Telephonic outreach to close HEDIS gaps for Medicaid pediatric population Assist members in addressing barriers to care, including scheduling challenges and transportation needs, to support access to primary care and overall well-being Collaborate with EPSDT Senior Quality Improvement Professional and Coordinator related to strategic outreach to maximize HEDIS outcomes Collaborate with other departments Provide vaccine awareness and education following Bright Futures and EPSDT preventive health guidelines Empower member independence through education and outreach that promote ongoing self-sufficiency in managing preventive and primary care needs Other responsibilities as assigned Use your skills to make an impact Required Qualifications Unrestricted Licensed Practical Nurse (LPN) in

Become a part of our caring community The Care Management Support Assistant contributes to administration of care management. Provides non-clinical support to the assessment and evaluation of members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. The Care Management Support Assistant performs basic administrative/clerical/operational/customer support/computational tasks. Typically works on routine and patterned assignments. The Care Management Support Assistant will review inbound referrals and correspondence for processing, fulfilment or resolution utilizing all appropriate software systems and resources. Screen physician’s orders and documentation to identify that all qualifying medical documentation and required information is included. When necessary, request additional applicable information from referring entity. Perform verification of benefits coverage and eligibility for services per Health Plan contract. Review referral data matching it against specified medical terms and diagnoses or procedure codes and follow established procedures for approving request or referring request for further review. Provide referral management education to members and providers regarding medical benefits, referral status and prior authorizations. Communicate with patient to confirm demographics and explain the details of the services/care requested. Coordinate the timely delivery of care and services with providers. Also communicate with referring entities, providers, and members regarding final referral determination while maintaining detailed documentation to record patient, physician, referral source and provider interactions and communications. Work with Pre-Authorization, Utilization Management, Billing, Pharmacy, and Home Care r

Become a part of our caring community The Medical Director, National Outpatient Medicare leverages clinical expertise and medical judgment to review preauthorization requests for services. This role is responsible for evaluating moderately complex to complex cases, where analysis of clinical information and situational factors requires in-depth assessment and sound decision-making. As a Medical Director at Humana , you will use your clinical expertise and judgment to make meaningful coverage and care determinations that support quality, consistency, and compliance across the healthcare continuum. In this role, you will review requests for services, level of care, and site of service, using nationally recognized clinical guidelines, CMS policies, medical references, and internal clinical resources to guide decision-making. This position offers the opportunity to work on complex outpatient cases , review clinical documentation, and collaborate with both internal partners and external physicians to gather additional information and discuss determinations. You may also contribute to care management activities and, depending on the role, provide input on areas such as clinical documentation, coding, grievances and appeals, and outpatient services or equipment reviews. Beyond case review, this role provides the opportunity to build strong relationships with physicians, provider groups, facilities, and community partners in support of regional priorities. It is a strong fit for physicians who are interested in contributing to value-based care, population health, and care management strategies while working in a structured environment that values sound clinical judgment, collaboration, and operational excellence. Humana is seeking a Medical Director to

Become a part of our caring community The Senior Product Owner is responsible for conveying product vision and roadmap to an Agile delivery team by defining user stories and prioritizing product backlog. The Senior Product Owner work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior Product Owner maximizes value of product created by Agile team. Liaises with stakeholders and the development team ensuring the right product is being built, in the right order, within budget and by the deadline. Serves as the Agile team's primary contact for information, work prioritization, and decision-making. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, andwork is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments. This is a remote position and you will report to the Director, Product Management. This position is created specifically to assist with Humana's efforts to secure and, if awarded, transition into a new business opportunity. Please note that continued employment in this role is expressly contingent upon Humana's receipt of the business opportunity and a satisfactory transition into the work. In the event Humana does not pursue the opportunity or determines that a timely and satisfactory transition cannot be achieved, employment may be subject to termination. Use your skills to make an impact Required Qualifications You will have a Bachelors degree or equivalent You will have 3+ years of technical experience, product ownership, or project management experience You will be Certified SAFe®

Become a part of our caring community The Senior Compliance Professional ensures compliance with governmental requirements. The Senior Compliance Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. Regulatory Compliance – State Enterprise Intake and Implementation – Senior Compliance Professional The Senior Compliance Professional implements new statues, regulations, rules and other regulatory guidance issued by state and federal regulators across the enterprise. Coordinates business partner engagement and implementation of rules. Researches compliance issues and recommends changes that ensure compliance with regulatory obligations. Provides compliance guidance and direction to business partners. Monitors metrics and other oversight tools that track implementation activity. Recommends new measures of compliance performance. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding implementation components. Exercises considerable latitude in determining objectives and approaches to assignments. The Senior Compliance Professional's primary focus will be to implement new federal and state rules, including PBM, across the enterprise. Key responsibilities may include: Serve as the subject matter expert and point-of-contact for individual state and federal implementations, leading implementation activity from onset to conclusion. Research, understand, and apply laws, regulations, and regulatory guidance for federal and state compliance issues. Analyze business requirements and complex issues, conduct research, and provide regulatory guidance to business partners, Law, Risk, and Compliance associate and leaders with regard to federal

Become a part of our caring community The Senior Quality Improvement Professional leads efforts to improve clinical quality and provider performance for the Humana Healthy Horizons in South Carolina Medicaid Plan. You will develop and implement cross-functional quality improvement initiatives, evaluate business processes and performance outcomes, and drive sustainable, measurable improvements. Reporting to the Quality Improvement Director, you will collaborate with internal and external stakeholders to advance a provider-focused culture of quality and performance excellence. You will manage complex projects and analyze diverse data sources to identify opportunities, inform strategy, and support organizational objectives. The Senior Quality Improvement Professional leverages data to lead quality improvement initiatives, monitor performance metrics, and support provider performance enhancement. This role collaborates with provider-facing teams to implement targeted interventions, develop educational resources, and drive achievement of quality and member experience goals. The position leads and participates in multidisciplinary committees, provides strategic clinical guidance on quality initiatives, and influences business decisions through data-driven insights. Operating with a high degree of independence, the Senior Quality Improvement Professional manages complex projects, exercises sound judgment, and recommends solutions to advance organizational objectives. Essential Role Responsibilities The Senior Quality Improvement Professional is responsible for improving clinical quality and performance outcomes among South Carolina network providers. Key responsibilities include: Partner with Provider Engagement, Network, and Contracting teams to implement clinical quality improvement strategies including education, training and performanc

Become a part of our caring community Humana’s Quality and Cost Strategy Analytics Team is seeking a Research Scientist 2 (Remote). Healthcare is rapidly changing, and our members are living longer, often with more chronic conditions. The Quality and Cost Strategy Analytics team identifies opportunities and build solutions to improve clinical outcomes and lower costs for millions of Medicare Advantage beneficiaries leveraging data science & analytics, clinical expertise, strategic mindset, and rigorous study designs. In this multi-disciplinary team, you will have the opportunity to work closely with strategy partners and clinicians to shape Humana’s future enterprise clinical strategies and initiatives. The Research Scientist 2 will lead research, evaluation and development of opportunities that optimize healthcare delivery, lower medical cost while improve member health outcomes, through applying mathematical, statistical, epidemiologic and data science methods. The Research Scientist 2 will also partner with stakeholders across the enterprise to identify, prioritize and measure the impact of core and novel solutions to significant problems in healthcare and improve the health of especially underserved population, using high volumes of structured and unstructured data. Responsibilities As a Research Scientist 2, you will: Research, prototype and scale new ideas to improve population health and healthcare delivery Collaborate with analytic and business teams to set objectives, approaches, and work plans Collaborate with strategy to evaluate existing programs and identify and measure new solutions to impact healthcare Leverage a wide range of analytics methods ranging from descriptive to prescriptive to transform high volumes of complex data into analytics solut

Become a part of our caring community Professional member of patient’s treatment team who provides skilled nursing visits in patient’s home under the direction of plan of treatment stablished with physician and input from patient/caregiver. Provides supervision for Aide and LPN as needed DUTIES AND RESPOSIBILITIES: • Provide initial and on-going assessment of client needs using the OASIS data elements incorporated into the Comprehensive Assessment. • With input from patient/caregiver and in conjunction with physician, formulates and implements plan of care. • Evaluate effectiveness of care plan and make necessary adjustments. • Provides for emotional and physical comfort and safety of client taking into consideration their rights and cultural background. • Receives and transcribes physician orders. • Notify physician and Agency supervisor of unusual reactions and/or changes in client’s condition. • Documents all appropriate observations and treatments in keeping with Agency policies and procedures. • Participates in case conferences, team meetings, staff meetings and Performance Improvement activities as assigned. • Provide supervision for Licensed Practical Nurses and/or Home Health Aide as assigned. • Provide any skilled nursing service for which appropriately trained which is prescribed under the plan of care. • Provide monthly summary of skilled services and clients outcomes to physician and Agency supervisor in keeping with Agency policies and procedures. Provides information for 60-day progress reports. • Adhere to all Agency policies and procedures including but not limited to HIPPA Privacy rule. • Maintains strict confidentiality of all patients, employee and Agency

Become a part of our caring community The Senior Process Improvement Professional analyzes and measures the effectiveness of existing business processes and develops sustainable, repeatable and quantifiable business process improvements. The Senior Process Improvement Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Humana Pharmacy Benefits Management (PBM) Strategy Enablement team partners with PBM teams to improve processes that will help our members improve their lives through better health outcomes. This role, within the Process Improvement (PI) team of Strategy Enablement, will work closely with PBM leaders, as well as key partners in leading and delivering on initiatives and process capabilities that enable improved effectiveness, efficiency, and experiences (member, provider and associate). The Senior Process Improvement Professional: Researches best business practices within and outside the organization to establish benchmark data. Defines and leads business improvement projects aligned with business strategies and operational priorities. Collects and analyzes process data to initiate, develop and recommend business practices and procedures that focus on member experience, increased productivity and efficiency 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. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is perf

Become a part of our caring community The Senior Business Intelligence Engineer describes the tools, technologies, applications, and practices used to collect, integrate, analyze, and transform data into insightful and actionable business information. This position is a strategic analytics contributor responsible for developing complex, cross-functional reporting from conception through delivery in partnership with stakeholders to ensure insightful solutions align with organizational objectives and operational priorities. The ideal candidate demonstrates mature judgment, strong governance discipline, and ability to lead with ambition and scale. The Senior Business Intelligence Engineer role works assignments involving moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior Business Intelligence Engineer describes the tools, technologies, applications and practices used to collect, integrate, analyze, and present an organization's raw data to create insightful and actionable business information. Key Responsibilities Design and maintain BI dashboards and analytic solutions from end-to-end Partner with leaders to define KPIs and reporting that support business operations and strategy Ensure data accuracy, auditability, and traceability for regulatory reporting Optimize SQL queries and BI models for large-scale datasets Implement data governance standards including metric definitions and documentation Improve delivery processes, tools, and metrics to increase efficiency Serve as a trusted advisor to leaders, enabling informed decision-making through clear, data-driven communication and reporting Use your skills to make an impact Requi