Manager, Compliance Nurse

Humana

1d • Remote

About The Position

Become a part of our caring community The Manager, Compliance Nursing reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. Reporting to the Clinical Strategy and Practice Director, you will work within specific guidelines and procedures; apply advanced technical knowledge to solve moderately complex problems; receive assignments in the form of objectives and determines approach, resources, schedules and goals. Responsibilities include: Maintain NCQA accreditation and state contractual requirements with passage of UM standards, including timeliness of determinations, appropriateness of decision making and documentation in CGX and letters Ensures team meets all assigned work completion and submission deadlines (i.e letters, provider notification of decision, and reports); trends results to identify improvement opportunities Align procedures to improve associate productivity and quality to broaden role responsibilities for optimal outcomes Improve associate experience and member outcomes through innovation, identifying new ways of working using technology enhancements to streamline processes and create administrative efficiencies Requires cross departmental collaboration, and conducts briefings and area meetings, maintaining frequent contact with other managers across the market Use your skills to make an impact

Requirements

• Active Licensed Registered Nurse (RN) in your state of residence without disciplinary action and ability to obtain multiple licenses.
• 2+ years of compliance experience
• 2 years team lead, coaching, subject matter expert, and/or project leadership experience
• 1 year of Utilization Management experience
• Proficiency using Microsoft Office Word, Excel, PowerPoint

Nice To Haves

• Associate's Degree
• Management experience
• Compact licensure
• Behavioral Health Utilization and/or Case Management experience which may include working knowledge of any or all the following, Interqual, MCG, ASAM
• NCQA UM Behavioral Health Accreditation Requirements

Responsibilities

• Maintain NCQA accreditation and state contractual requirements with passage of UM standards, including timeliness of determinations, appropriateness of decision making and documentation in CGX and letters
• Ensures team meets all assigned work completion and submission deadlines (i.e letters, provider notification of decision, and reports); trends results to identify improvement opportunities
• Align procedures to improve associate productivity and quality to broaden role responsibilities for optimal outcomes
• Improve associate experience and member outcomes through innovation, identifying new ways of working using technology enhancements to streamline processes and create administrative efficiencies
• Requires cross departmental collaboration, and conducts briefings and area meetings, maintaining frequent contact with other managers across the market

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: Manager
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees