RN Compliance Nurse 2 Quality Assurance Audit - Remote

Profile

Job Information
Humana
RN, Compliance Nurse 2 (Quality Assurance Audit) - Remote
in
Tampa
Florida
Description
The RN, Compliance Nurse 2 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 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Responsibilities
The RN Compliance Nurse 2 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.
Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
Follows established guidelines/procedures.
Required Qualifications
Current Unrestricted RN license in the state where you reside.
Prior clinical experience in an acute care, skilled or rehabilitation clinical setting.
Experience with utilization management, pre-service denials and quality assurance audits.
This is a WAH position, you will be expected to work in Eastern time zone regardless of what time zone you reside in.
Excellent computer skills and ability to easily navigate multiple applications.
Proficiency in Microsoft Office Products Word, Excel, Outlook, Power Point
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.
You will be expected to report to the Market office with advanced notice for meetings and/or planned work functions.
Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
Work At Home Requirements
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Preferred Qualifications
BSN or Bachelor's degree in a related field.
Experience as a utilization management Auditor.
Health Plan experience working with large carriers.
Experience working with MCG/Interqual guidelines.
Bilingual (English, Spanish) a plus.
Additional Information
Interview Format
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 an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. (please be sure to check your spam or junk folders often to ensure communication isn't missed)
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 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.
Scheduled Weekly Hours
40

Company info

Sign Up Now - BilingualCrossing.com