Become a part of our caring community and help us put health first
 

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

The Compliance Nurse 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. Follows established guidelines/procedures.

Required Qualifications

• Less than 5 years of technical experience

• Licensed Registered Nurse (RN) in a compact state with no disciplinary action

• 3 or more years of progressive clinical experience

• Previous experience in utilization management, case management, discharge planning and/or home health, skilled nursing facility, or rehab

• Ability to be licensed in multiple states without restrictions

• Proficient with Microsoft Office products including Word, Excel and Outlook

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

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• BSN

• Experience working on a team performing auditing, quality and/or compliance

• Health Plan experience working with large carriers

• Previous Medicare/Medicaid experience a plus

• Experience working with Medicare Benefit Policy Manual (Chapter 7 and/or Chapter 8), MCG or Interqual guidelines

The standard operating hours are Monday to Friday between 8am and 5pm EST, with some flexibility depending on business needs. The Home Solutions/OneHome UM Team manages work nationwide with operating hours 8am to 8pm EST.

Occasional overtime may be required for this role.

Use your skills to make an impact
 

Required Qualifications

• Bachelor's degree
• Less than 5 years of technical experience
• Active RN license in the state(s) in which the nurse is required to practice
• Ability to be licensed in multiple states without restrictions
• A minimum of three years varied and progressive nursing experience
• Previous experience in utilization management, case management, discharge planning and/or home health, skilled nursing facility, or rehab
• Proficient with Microsoft Office products including Word, Excel and Outlook
• Ability to work independently under general instructions and with a team
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• BSN
• Health Plan experience working with large carriers
• Previous Medicare/Medicaid experience a plus
• Experience working with Medicare Benefit Policy Manual (Chapter 7 and/or Chapter 8), MCG or Interqual guidelines

Additional Information

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