Senior Compliance Registered Nurse

Become a part of our caring community and help us put health first
 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 ensures mandatory reporting 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. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

The Senior Compliance Nurse Responsibilities:

• Internal Audits and Monitoring: Conduct NCQA audits per assignment (including stretch assignments/ad hoc audits) to assess compliance with:

• Reporting and Documentation: Random selection and analysis of cases to assess outcome and metrics of market compliance with NCQA must pass UM elements.

• Audit Calibration: Verify findings to maintain data quality and validation for statistical reliability prior to revealing audit results to markets. 

• NCQA Fail-factor elements: Effectively ascertain the complicated and layered nuances of primary contributors to perceived examiner risks during a NCQA survey.

• Root Cause Analysis: Identify the key contributors of NCQA fail factors for tracking/trending purposes to mitigate issues prior to/during lookback periods and surveys. 

• Criteria and Policy: Collaborate with markets to ensure consistent application and understanding of criterion and policies are applied.

• Market Collaboration: Proactive planning and partnership to adequately support markets and communicate pertinent audit findings.

• Stakeholder Engagement: Large forum meeting facilitation to present, illustrate and discuss detailed and complex NCQA audit findings.

“Pre-Game” Meetings with Lead Medical Directors, Centralized Leadership, Compliance and all NCQA Auditors for collective consensus and consistency in audit approaches in preparation for market meetings.

Market Meetings with Market Leaders, Lead AMDs, Regional AMDs, Template Team, Accreditation Partners, Compliance, Centralized Letters Team, etc.), a collaborative forum to discuss audit findings with a “live” and rebuttal process; present a high-level overview of significant findings & trends; provide market support and education.

• Advisory Role: Serve as key advisors to market management on compliance-related matters related to audit findings.

• Cultivate Trust: Foster a united culture with key market stake holders to gain agreement on audit findings and reduce risks related to recognized issues.

• New Market Rollouts: Develop and refine NCQA audit tactics related to new Medicaid market implementation to ensure consistency in compliance and quality.

• Risk Management: Identify potential compliance risks and work with business partners to develop strategies to mitigate them.

• Adopt Best Practices: Proactive identification, risk reduction, and continuous monitoring to navigate and limit potential NCQA survey uncertainties.

• Benchmark Data: Monitoring audit measures’ effectiveness by leveraging and trending NCQA fail factor opportunities for improvements or adaptations in methodologies.

• Enhanced Decision-Making: Discuss and debate audit strategies’ efficacy and revisit audit approaches to secure team reliability and credibility.

• Training and Education: Partner with leadership to develop and deliver NCQA audit centered training to markets and business partners.

• Foster Awareness:  Communicate and provide understanding of pertinent issues, compliance requirements, and interpretation of NCQA standards.

• Shadow Sessions: Offer opportunities to observe audit procedures and fundamental contributors to NCQA fail factor elements. 

• Template Teams: Provide guidance and feedback in conjunction with business partners and Lead Medical Directors to ensure denial language is consistent across markets.

Use your skills to make an impact
 

Required Qualifications:

• Registered Nurse with a Bachelor's degree in Nursing, BSN, and an active multi-state enhanced licensure, (eNLC), without disciplinary action

• Minimum two, (2) years of experience in utilization management

• Intermediate proficiency using Microsoft Office Word, Excel, Outlook, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment.

• Excellent analytical and problem-solving abilities.

• Strong communication and interpersonal skills, with the ability to interact effectively with all levels of the organization.

• Proven ability to precept new associates, as well as develop and deliver training programs.

• Detail-oriented with strong organizational and project management skills.

• The ability to articulate complicated concepts

• Excellent presentation skills.

Preferred Qualifications

• Experience in physical health

• Experience in behavioral health

• In-depth knowledge of criteria (inclusive of hierarchy): MCG, ASAM, Market Policies and Handbooks, Peer Review Literature, etc.

• Working knowledge of NCQA UM letter requirements and compliance best practices.

• Working knowledge of NCQA UM letter requirements and compliance best practices.

Workstyle: Remote work at home

Location: Prefer Medicaid State, but open to all locations

Schedule: Monday - Friday 8:00 AM to 5:00 PM Eastern Time

Travel: Less than 5%

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. 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.

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.

Work at Home Guidance 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. Employees 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 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.

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.

 

$78,400 - $107,800 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.

Apply