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  • Quality Compliance Nurse Professional

    Humana (Richmond, VA)



    Apply Now

    Become a part of our caring community and help us put health first

     

    Humana Healthy Horizons in Virginia is seeking a Quality Compliance Nurse Professional 2 who will be focused on ensuring quality and safety of patient care. They will conduct quality reviews and research to support quality assurance. The Quality Compliance Nurse Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

     

    The Quality Compliance Nurse Professional 2 will conduct medical records reviews to ensure proper documentation, coding, coordination of care and service for our members as well as accurate reporting of outcomes.

     

    + Collects and analyzes data to develop process improvement strategies and/or corrective actions as needed.

    + Reviews medical records for supplemental data and enter data in supplemental data base.

    + Conducts medical record audits and assessments to evaluate compliance with established standards and to ensure compliance with National Committee for Quality Assurance (NCQA), Centers of Medicare & Medicaid Services (CMS) and Department of Medical Assistance Services (DMAS) standards.

    + Prepares for external audits and addresses any findings or corrective actions.

    + Tracks and monitors compliance Quality Management Reviews (QMR) reporting requirements and documentation.

    + Analyzes clinical data and quality metrics to identify trends, areas for improvement, and compliance issues.

    + Prepares reports for senior management and other functional areas.

    + Works closely with clinical and administrative staff to promote best practices in quality care and ensure alignment with compliance goals.

     

    Use your skills to make an impact

    Required Qualifications

    + **Must reside in the Commonwealth of Virginia.**

    + An active, unrestricted licensed Practical Nurse (LPN) or a licensed Registered Nurse (RN) with an active, unrestricted license in the Commonwealth of Virginia.

    + One (1) or more years of professional experience in medical audits and clinical reviews.

    + One (1) or more years of experience working with quality in a fast-paced insurance or health care setting.

    + Experience working with healthcare providers.

    + Comprehensive knowledge of Microsoft Word, Excel and PowerPoint.

    + Excellent communication skills, both oral and written.

    + Strong relationship building skills.

    + Ability to travel to region-based providers and members for face-to-face interviews, quality onsite audits and medical reviews.

    + This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

    + This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

    Preferred Qualifications

    + BSN or bachelor’s degree in health administration or a related field.

    + One (1) or more years of experience working directly with Healthcare Effectiveness Data and Information Set (HEDIS) measures and quality improvement initiatives measures.

    + Three (3) years of managed care health plan experience.

    + Knowledge of Humana's internal policies, procedures and systems.

    + Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations and assistance. _See “Additional Information” section for more information._

    Additional Information

    + **Workstyle:** This is a remote position with travel.

    + **Travel:** Up to 25% to region-based providers and members for face-to-face interviews, quality onsite audits and medical reviews. You may be required to attend onsite team engagement meetings in Humana Healthy Horizons, Glen Allen, VA office location.

    + **Typical Workdays/Hours:** Monday – Friday; 8:00am -5:00pm, Eastern Standard Time (EST).

    + **Language Assessment Statement:** Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

     

    WAH Internet Statement

    To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

    + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.

    + Satellite, cellular and microwave connection can be used only if approved by leadership.

    + Humana will provide Home or Hybrid Home/Office employees 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.

     

    Interview Format

     

    As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

     

    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

     

    The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

     

    $71,100 - $97,800 per year

     

    This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

     

    Description of Benefits

     

    Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our 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.

     

    About us

     

    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. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

     

    ​

     

    Equal Opportunity Employer

     

    It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

     

    Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

     


    Apply Now



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