Become a part of our caring community
 

The Compliance Nurse 2 reviews case management and utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse to ensure appropriate course of action. The Compliance Nurse 2 understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Position Responsibilities

• 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.

Use your skills to make an impact
 

Required Qualifications

• 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 two, (2) years of auditing experience preferably in a clinical or MCO setting

• 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

• Previous experience with Managed Care Organization.

• Ability to work independently under general instructions and with a team

• Exceptional oral and written communication and interpersonal skills

Preferred Qualifications

• Bachelor’s Degree in Nursing

• Medicare/Medicaid, DMAS, CMS, and NCQA experience 

Workstyle:  Remote work at Home

Location: Virginia or reside within 40 miles of one of the following contiguous bordering states - Tennessee, West Virginia, North Carolina, Maryland, or Kentucky

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

Travel: 25% travel within the Commonwealth of Virginia for meetings or compliance assurance audits

Work at Home/Remote Requirements To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home 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. 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

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.

 

$71,100 - $97,800 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
 

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

​
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.