Quality Assurance Professional

Humana•Chittenden, VT

4d•$65,000 - $88,600•Remote

About The Position

The Quality Assurance Professional reviews Long-Term Services and Support (LTSS) contractor documentation and performance to ensure compliance with contract scope of work and state and federal regulations. The role ensures adherence to policies, procedures, and regulations, and helps prevent and detect fraud, waste, and abuse so that appropriate action can be taken. The position requires understanding department, segment, and organizational strategy and operating objectives and their relationship to related areas. Work assignments are varied and frequently require interpretation and independent determination of appropriate courses of action. This is a remote position for candidates who reside in Michigan or within 40 miles of the Michigan border in Ohio or Indiana. The schedule is Monday through Friday, 8:00 AM to 5:00 PM Eastern Time, for 40 hours per week. Travel may be up to 10%, including occasional trips to Humana’s Detroit location for audits, accreditation-related activities, team engagement, training, or meetings. Home-based employees must have internet service with at least 25 Mbps download and 10 Mbps upload speed and a dedicated workspace that protects member PHI/HIPAA information. The position offers a starting base-pay range of $65,000 to $88,600 per year and is eligible for a bonus incentive plan based on company and/or individual performance. Humana offers medical, dental, and vision benefits; a 401(k) retirement savings plan; paid time off and company and personal holidays; paid parental and caregiver leave; short- and long-term disability; life insurance; and other benefits.

Requirements

Must reside in Michigan or within a 40-mile radius of the Michigan border in Ohio or Indiana.
Bachelor’s degree.
At least two years of experience in care management, utilization management, quality assurance, and/or population health supporting the LTSS population.
Previous experience working with a Managed Care Organization.
Proficiency in analyzing, tracking, and interpreting data trends to identify improvement opportunities and ensure adherence to operational guidelines, policies, and procedures.
Proficiency with Microsoft Office products, including Word, Excel, PowerPoint, and Outlook.

Nice To Haves

Michigan healthcare professional license, such as LPN, RN, LMSW, or LBSW.
Previous Medicare/Medicaid, MDHHS, CMS, and NCQA experience.

Responsibilities

Conduct and summarize compliance audits and reports, including deficiencies and risks.
Collect and review records, summarize issues, and analyze data daily, weekly, monthly, or as needed to assess team and individual outcomes and operational metrics.
Conduct inter-rater reliability audits of vendor activities, including HCBS service calculators and nursing facility level-of-care determination assessments, to ensure accurate and consistent application of state and Humana guidelines.
Ensure compliance with Michigan Department of Health and Human Services (MDHHS), National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and Humana Gold-Plus Integrated policies and procedures.
Complete audits on time and communicate results to leadership.
Make decisions about own work methods, including occasionally in ambiguous situations, with minimal direction and guidance as needed.
Perform other duties as assigned by the LTSS leadership team.