Humana

Compliance Nurse – Medicaid

Humana

full-time

Posted on:

Location Type: Hybrid

Location: Virginia • United States

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Salary

💰 $71,100 - $97,800 per year

About the role

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

Requirements

  • 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 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 yrs 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.
Benefits
  • medical, dental and vision benefits
  • 401(k) retirement savings plan
  • 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
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
data analysiscompliance auditingmedical record auditingoperational metrics assessmentreport summarizationrisk analysisnursingaudit experiencedecision makingtroubleshooting
Soft Skills
independent workteam collaborationcommunication skillsinterpersonal skillsleadershipadaptabilityproblem solvingtime managementattention to detailcritical thinking
Certifications
Registered Nurse licensemulti-state nursing license (eNLC)