RN Compliance QA Auditor - Humana
Augusta, ME
About the Job
Become a part of our caring community and help us put health first
The RN, Compliance Nurse 2, Quality Assurance Auditor reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse.
The RN, Compliance Nurse 2, Quality Assurance Auditor ensures mandatory reporting is completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals.
+ Perform pre-service denial and quality assurance audits and summarize findings for the clinical operational teams to initiate and identify needed corrective action plans
+ Makes necessary revisions and edits to member pre-service denial letters prior to mailing to ensure compliance with Medicare requirements
+ Analyze authorizations and medical records in accordance with specified departmental policies and regulatory requirements
+ Provide detail audit results which can include issues on absence of documentation, incorrect decision making, non-compliance with timeliness request, not using established criteria for decision making, or not following departmental processes
+ Responsible for internal and external communications to obtain needed information and/or verify data related to the audit functions
+ Recommend process changes or training opportunities related to audit trends to the clinical operational teams
+ Coordinate special compliance projects and any additional tasks as determined by leadership
Use your skills to make an impact
Required Qualifications
+ Current Unrestricted Florida RN license or Compact RN License the state where you reside
+ Clinical experience in an acute care, skilled and/or rehabilitation clinical setting
+ Experience with utilization management, pre-service denials and/or quality assurance audits
+ Proficiency in Microsoft Office Products Word, Excel, and Power Point
Preferred Qualifications
+ BSN or Bachelor's degree in a related field.
+ Bilingual (English, Spanish)
+ Experience as a utilization management Auditor
+ Health Plan experience working with large carriers
+ Experience working with MCG/Interqual guidelines
+ Microsoft Outlook
+ Excellent computer skills and ability to easily navigate multiple applications
Additional Information
+ Work Days/Hours: Monday - Friday; 8am-5pm EST, with Overtime as needed based on the needs of the business.
+ Rotating weekend coverage (with a day off during the week) with others on the team will be required.
+ Travel to Market office with advanced notice for meetings and/or planned work functions.
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Work at Home Guidance
To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates 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
+ Satellite, cellular and microwave connection can be used only if approved by leadership
+ Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
+ 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
Internal- If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/yammer and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.
Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide their social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana's secure website.
#LI-BB1
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.$69,800 - $96,200 per yearThis 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
About CarePlus Health Plans: CarePlus Health Plans is a recognized leader in healthcare delivery that has been offering Medicare Advantage health plans in Florida over 23 years. CarePlus strives to help people with Medicare, or both Medicare and Medicaid, achieve their best possible health and wellness through plans with benefits and services they care about. As a wholly owned subsidiary of Humana, CarePlus currently serves Medicare beneficiaries throughout 21 Florida counties.About Humana: Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers, and our 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. 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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
The RN, Compliance Nurse 2, Quality Assurance Auditor reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse.
The RN, Compliance Nurse 2, Quality Assurance Auditor ensures mandatory reporting is completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals.
+ Perform pre-service denial and quality assurance audits and summarize findings for the clinical operational teams to initiate and identify needed corrective action plans
+ Makes necessary revisions and edits to member pre-service denial letters prior to mailing to ensure compliance with Medicare requirements
+ Analyze authorizations and medical records in accordance with specified departmental policies and regulatory requirements
+ Provide detail audit results which can include issues on absence of documentation, incorrect decision making, non-compliance with timeliness request, not using established criteria for decision making, or not following departmental processes
+ Responsible for internal and external communications to obtain needed information and/or verify data related to the audit functions
+ Recommend process changes or training opportunities related to audit trends to the clinical operational teams
+ Coordinate special compliance projects and any additional tasks as determined by leadership
Use your skills to make an impact
Required Qualifications
+ Current Unrestricted Florida RN license or Compact RN License the state where you reside
+ Clinical experience in an acute care, skilled and/or rehabilitation clinical setting
+ Experience with utilization management, pre-service denials and/or quality assurance audits
+ Proficiency in Microsoft Office Products Word, Excel, and Power Point
Preferred Qualifications
+ BSN or Bachelor's degree in a related field.
+ Bilingual (English, Spanish)
+ Experience as a utilization management Auditor
+ Health Plan experience working with large carriers
+ Experience working with MCG/Interqual guidelines
+ Microsoft Outlook
+ Excellent computer skills and ability to easily navigate multiple applications
Additional Information
+ Work Days/Hours: Monday - Friday; 8am-5pm EST, with Overtime as needed based on the needs of the business.
+ Rotating weekend coverage (with a day off during the week) with others on the team will be required.
+ Travel to Market office with advanced notice for meetings and/or planned work functions.
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Work at Home Guidance
To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates 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
+ Satellite, cellular and microwave connection can be used only if approved by leadership
+ Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
+ 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
Internal- If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/yammer and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.
Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide their social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana's secure website.
#LI-BB1
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.$69,800 - $96,200 per yearThis 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
About CarePlus Health Plans: CarePlus Health Plans is a recognized leader in healthcare delivery that has been offering Medicare Advantage health plans in Florida over 23 years. CarePlus strives to help people with Medicare, or both Medicare and Medicaid, achieve their best possible health and wellness through plans with benefits and services they care about. As a wholly owned subsidiary of Humana, CarePlus currently serves Medicare beneficiaries throughout 21 Florida counties.About Humana: Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers, and our 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. 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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
Source : Humana