Compliance Registered Nurse

Humana•Columbia, SC

3d•Remote

About The Position

Become a part of our caring community and help us put health first The Compliance Registered Nurse 2 role directly supports the organization's ability to maintain contractual compliance, achieve and sustain NCQA accreditation, and mitigate risk through diligent oversight, policy enforcement, and ongoing education. The role of a Compliance Nurse will be to manage state contracts, policies, NCQA accreditation requirements, and monthly auditing. This is critical in ensuring organizational adherence to regulatory standards and internal protocols. This position is responsible for the implementation, oversight, and continuous monitoring of compliance with both state and federal regulations, as well as industry accreditation requirements such as those established by the National Committee for Quality Assurance (NCQA). In this role you will ensure mandatory reporting is completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. 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. Use your skills to make an impact

Requirements

Active RN license in the state of South Carolina
1-2 years’ experience with National Committee for Quality Assurance (NCQA) and state audits
Proficient with Microsoft Office products including Word, Excel and Outlook
Ability to work independently under general instructions and with a team
Must be passionate about contributing to an organization focused on continuously improving consumer experience
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 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.

Nice To Haves

BSN
Health Plan experience working with large carriers
Previous Medicare/Medicaid experience a plus
Previous experience in utilization management, case management, discharge planning and/or home health or rehab
Certification in Case Management a plus (CCM)
Knowledge with MCG or Interqual guidelines

Responsibilities

Manage state contracts, policies, NCQA accreditation requirements, and monthly auditing.
Implementation, oversight, and continuous monitoring of compliance with both state and federal regulations, as well as industry accreditation requirements such as those established by the National Committee for Quality Assurance (NCQA).
Ensure mandatory reporting is completed.
Conducts and summarizes compliance audits.
Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals.