[Hiring] Quality Assurance Professional @Humana

Role Description

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. You will ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse to ensure appropriate course of action. Your work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

• Comply, conduct, and summarize compliance audits/reports to include deficiencies and risks.
• Collect, review records, summarize issues and analyze data daily, weekly, monthly, or as needed to assess outcome and operational metrics for the team and individuals.
• Conduct inter-rater reliability audits for multiple vendor activities such as Home- and Community-Based Services (HCBS) service calculators and nursing facility level of care determination assessments to ensure accurate and consistent application of state and Humana guidelines.
• Ensure 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 Policy and Procedures are followed.
• Ensure auditing is completed timely and communicated with leadership.
• Make decisions regarding own work methods, occasionally in ambiguous situations, and require minimal direction and receives guidance where needed.
• Other duties as assigned by the LTSS leadership team.

Qualifications

• Must reside in Michigan or within a 40-mile radius of the Michigan border in Ohio or Indiana.
• Bachelor's degree.
• Two (2) or more years of experience in care management, utilization management, quality assurance and/or population health supporting the Long-Term Services and Supports (LTSS) population.
• Previous experience working with Managed Care Organization.
• Proficiency in analyzing, tracking, and interpreting data trends to identify improvement opportunities and ensure adherence to operational guidelines, policies, and procedures.
• Proficient with Microsoft Office products including Word, Excel, PowerPoint, and Outlook.

Requirements

• Licensed healthcare professional in the state of Michigan: LPN, RN, LMSW, LBSW (Preferred).
• Previous Medicare/Medicaid, MDHHS, CMS, and NCQA experience (Preferred).

Benefits

• Medical, dental and 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.
• Many other opportunities.

Company Description

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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.