Log In
Sign Up
Summary:
Humana is seeking a Senior Compliance Registered Nurse to manage compliance audits and review utilization management activities to ensure adherence to policies and regulations. The role focuses on identifying risks related to fraud, waste, and abuse and is based remotely in various U.S. locations. The Senior Compliance Nurse will collaborate with stakeholders to mitigate compliance risks and improve market performance.
Responsibilities:
-
Conduct NCQA audits to assess compliance with required standards.
-
Analyze case documentation and outcome metrics to track compliance.
-
Perform audit calibration to ensure data quality.
-
Engage in root cause analysis to identify contributors to NCQA fail factors.
-
Collaborate with markets to ensure proper application of criteria and policies.
-
Participate in meetings to discuss audit findings and offer guidance.
-
Provide strategic advisory support to market management regarding audit outcomes.
-
Develop NCQA audit strategies for new Medicaid market implementations.
-
Work with stakeholders to reduce risks and improve market collaboration.
-
Lead training sessions to enhance audit compliance awareness and effectiveness.
Requirements:
-
Bachelor’s Degree in Nursing (BSN) and active multi-state enhanced licensure (eNLC).
-
At least two years of experience in utilization management.
-
Proficiency with Microsoft Office Suite and basic troubleshooting skills in a remote environment.
-
Strong analytical, problem-solving, and organizational skills.
-
Excellent communication and interpersonal skills.
-
Ability to precept new associates and deliver training programs.
-
Detail-oriented with project management skills.
Benefits:
-
Competitive benefits package, including medical, dental, and vision plans.
-
401(k) retirement savings plan.
-
Paid time off, including holidays and volunteer time off.
-
Short-term and long-term disability, life insurance, and paid parental leave.
-
Incentive bonus plan based on performance.
