[Hiring] Compliance Nurse @Humana

Role Description

Become a part of our caring community and help us put health first. The Compliance Nurse 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 understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Compliance Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Position Responsibilities

• Ensures mandatory reporting completed.
• Complies, conducts, and summarizes compliance audits/reports to include deficiencies and risks.
• Collects, reviews 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 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.

Qualifications

• Must reside in the Commonwealth of Virginia or within a 40-mile radius from Virginia in a bordering state/district (Washington DC, MD, WV, KY, TN & NC).
• Bachelor's degree.
• Active Registered Nurse license in the state of Virginia, or obtain a multi-state license in a bordering contiguous state that participates in the enhanced licensure (eNLC) without disciplinary action.
• Minimum three (3) years of experience in an MCO environment.
• 2 years previous audit experience.
• Minimum three (3) years of nursing experience.
• 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.
• CMS, NCQA, and DMAS guidelines.
• Ability to work independently under general instructions and with a team.
• Exceptional oral and written communication and interpersonal skills.

Preferred Qualifications

• BSN.
• Health Plan experience working with large carriers.
• Previous Medicare/Medicaid experience.
• Previous experience in utilization management, case management, discharge planning, and/or home health or rehab.
• Case Management experience.

Requirements

• 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.
• Schedule: Monday - Friday 8:00 AM to 5:00 PM Eastern.
• Travel: 25% travel within the Commonwealth of Virginia for meetings or compliance assurance audits.

Work at Home/Remote Requirements

• To ensure Hybrid Office/Home associates' ability to work effectively, the self-provided internet service 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.

Additional Information

• SSN Alert: Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file.
• Interview Format: As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue.
• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
• Scheduled Weekly Hours: 40.
• Pay Range: $71,100 - $97,800 per year. This job is eligible for a bonus incentive plan.

Benefits

• Humana, Inc. offers competitive benefits that support whole-person well-being.
• 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.

Company Description

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it.