Compliance Registered Nurse

Humana

5d • Remote

About The Position

Become a part of our caring community The Compliance Nurse 2 reviews case management and utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse to ensure appropriate course of action. The Compliance Nurse 2 understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Requirements

• Active Registered Nurse license in the state of Virginia, or obtain a multi-state license a bordering contiguous state that participates in the enhanced licensure, (eNLC) without disciplinary action
• Minimum two, (2) years of auditing experience preferably in a clinical or MCO setting
• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment
• Previous experience with Managed Care Organization.
• Ability to work independently under general instructions and with a team
• Exceptional oral and written communication and interpersonal skills
• Workstyle: Remote work at Home Location: Virginia or reside within 40 miles of one of the following contiguous bordering states - Tennessee, West Virginia, North Carolina, Maryland, or Kentucky
• 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.
• 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

• Bachelor’s Degree in Nursing
• Medicare/Medicaid, DMAS, CMS, and NCQA experience

Responsibilities

• Ensures mandatory reporting completed.
• Complies, conducts, and summarizes compliance audits/reports to include deficiencies and risks.
• Collects, review records, summarizes issues and analyzes data daily, weekly, monthly, or as needed to assess outcome and operational metrics for the team and individuals to determine appropriate course of action.
• Audits CM medical records and operation for compliance.
• Proficiency in analyzing, tracking, and interpreting data trends, operational guidelines and procedures are adhered to.
• Ensures DMAS Cardinal Care Guidelines, NCQA, CMS, and Humana's Healthy Horizon's Policy and Procedures are followed.
• This is a mainly a virtual position, however, it may require occasional travel for meetings or audits to ensure accreditation is met.
• Ensures auditing is completed timely and communicated with leadership.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Other duties as assigned per CM or Quality leadership.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees