Compliance UM Nurse (Wed - Sun)

Humana • Carolina, KY

3d • Remote

About The Position

The Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. This role will follow a four-day, 10-hour shift schedule within a Wednesday through Sunday work week. The assigned schedule will be either Wednesday through Saturday or Thursday through Sunday, with work hours scheduled between 8:00 a.m. and 8:00 p.m. Eastern Time. The Compliance Nurse 2 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 workstreams. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Assignments are varied and often complex, requiring independent judgment, critical thinking, and interpretation of guidelines to determine appropriate courses of action. Follows established guidelines, regulatory turnaround times, and procedures for processing QIO fast track appeals and expedited authorization requests.

Requirements

• Licensed Registered Nurse (RN) in a compact state with no disciplinary action.
• Must have valid compact license or reside in a compact state and be eligible to upgrade to compact licensure.
• Three (3) or more years of consecutive UM experience for a health plan OR two (2) or more years of consecutive UM auditing experience in a traditional Quality or Compliance role at a health plan OR one (1) or more years of home health utilization management experience for a health plan.
• Effective telephonic and virtual communication skills.
• Comprehensive knowledge of Microsoft Word, Outlook and Excel.
• Ability to work independently under general instructions and within a team.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences.
• Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role).
• A minimum standard speed for optimal performance is 25mbs download x 10 mbs upload.
• A dedicated office space lacking ongoing interruptions so you can meet productivity requirements, and to protect member PHI / HIPAA information.
• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice To Haves

• Current member of the One Home / Home Solutions UM Team who has been in their current position for 12+ months.
• Bachelor’s degree in nursing or related field.
• Clinical experience in a home health and/or Skilled Nursing Facility setting.
• Clinical experience working QIO appeals, expedited request reviews and/or compliance.
• Health Plan experience.

Responsibilities

• Reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations.
• Prevents and detects fraud, waste, and abuse.
• Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals.
• Follows established guidelines, regulatory turnaround times, and procedures for processing QIO fast track appeals and expedited authorization requests.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level