Utilization Management Compliance Registered Nurse, RN

Description

The 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 Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Compliance Nurse 2 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. 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. Reviews denial letters issued to members and providers to ensure compliance with accreditation entities and State contractual requirements. Follows established guidelines/procedures.

Required Qualifications

• Active Licensed Registered Nurse, (RN), in your state of residence without disciplinary action and ability to obtain multiple licenses.

• A minimum of three years varied clinical nursing experience.

• 2 years of experience in utilization management with MCG Guidelines

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

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

Workstyle: Remote work at Home

Location:  Compact State Preferred

Schedule:

• Must be able to work an 8-hour shift Monday through Friday 8:30 – 6:30 Eastern Time

• Ability to work weekends and holidays on a rotating schedule. (about 2 weekend per month, and 2 holidays per year)

Travel:   1 to 2 time annually to the local market office as needed for meetings

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

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates 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 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

Preferred Qualifications

• BSN

• Behavioral Health Utilization Management

• Health Plan experience working with large carriers

• Previous Medicare/Medicaid experience a plus

• Certification in Case Management a plus (CCM)

• Experience with National Committee for Quality Assurance (NCQA) requirements

Additional Information

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Modern Hire Voice 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.

If you are selected for a first-round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn’t missed) inviting you to participate in a Modern Hire Voice interview. In this interview, you will listen to a set of interview questions over your phone, and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/Buzz and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a