Senior Compliance Nurse

Humana • Louisville, KY

272d • $78,400 - $107,800 • Onsite

About The Position

The Senior Compliance Nurse reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Senior Compliance Nurse work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior Compliance Nurse is responsible for maintaining, updating and submitting clinical coverage policies for the Kentucky Medicaid market. Additionally, this role is responsible for completing audits of records to ensure compliance with process and expectations. This role also helps to support compliance and contractual auditing and data requests from Kentucky Department for Medicaid services.

Requirements

• Unrestricted Registered Nurse license in the state of Kentucky or have a compact license.
• Bachelor's degree or 5 years or more relevant experience in lieu of degree.
• 5+ years of technical experience with proficiency in Microsoft Office (Excel, Word, PowerPoint, Visio) and other virtual platforms (e.g., Zoom, Teams).
• 2 years Medicare/Medicaid or Health Plan Experience in Utilization Management.
• Great communication skills - written and verbal.
• Knowledge of compliance auditing and NCQA UM Requirements.
• Experience with reviewing data to identify trends, process gaps, and/or associate learning opportunities.
• Experience with leading process change initiatives.
• Experience utilizing MCG.

Nice To Haves

• MCG Certification.
• Experience with creating data presentations in the form of graphs/charts/graphics.
• Presentation skills on reporting.
• Proficient working with CGX, QuickBase.
• Project Management Experience.
• Bilingual in any language in addition to English.

Responsibilities

• Review utilization management activities and documentation.
• Ensure adherence to policies, procedures, and regulations.
• Prevent and detect fraud, waste, and abuse.
• Maintain, update, and submit clinical coverage policies for the Kentucky Medicaid market.
• Complete audits of records to ensure compliance.
• Support compliance and contractual auditing and data requests.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, including company and personal holidays, volunteer time off, paid parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree