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

The Quality Audit Professional 2 supports the Healthcare Quality Management Team in administering and implementing the Clinical Quality Management Program (CQMP) in support of TRICARE’s commitment to quality healthcare for beneficiaries.

Humana Government Business government contract requires U.S. citizenship for this position. 

The Clinical Quality Registered Nurse (RN) collects and reviews records, summarizes issues, works with Medical Director as needed, and implements corrective actions as assigned. Coordinates case presentations and presents to Patient Safety Peer Review Committee. Audits quality cases for compliance and participates in department projects as available. 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, requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Key Accountabilities:

• 30%    Reviews medical records, creates case summaries, and presents potential quality issue (PQI) cases to Medical Director for review.
• 20%    Review PQI’s from all sources to determine the need for medical record review.
• 15%    Provides assistance to Medical Directors to ensure corrective action plans (CAPs) are developed & implemented as identified through quality management reporting. Monitors CAP for timeliness and enters data into the Provider Trending Database according to Policy and Procedure.
• 15%    Monitors cases entered in the Clinical Quality Management Database (CQMD) for accuracy, timeliness of completion, and documentation.
• 10%    Participates in case presentation and discussion at Patient Safety Peer Review Committee (PSPRC) meetings.
• 10%    Participates in departmental projects such as focused reviews as available.

Use your skills to make an impact
 

Required Qualifications 

• Our Department of Defense contract requires U.S. Citizenship for this role
• Successfully receive approval for government security clearance (Via National Background Investigation Services NBIS)
• 3 or more years of clinical nursing experience
• Active R.N. (Registered Nurse) license in state of employment
• 2 or more years of Utilization Review (UR), Case Management (CM) or Quality Management (QM) experience 
• Provide coverage in the Eastern Time Zone hours
• Ability to work independently under general instructions, self-directed and motivated
• Strong analytical skills, able to manipulate and interpret data
• Comprehensive knowledge of Microsoft Office Word, Excel and PowerPoint

Preferred Qualifications 

• Accreditation (URAC, NCQA or JCAHO) experience
• Clinical nursing experience in a hospital or physician office practice
• Knowledge of HEDIS/Stars/CMS/Quality

Additional Information  

**PLEASE MAKE SURE YOU ATTACH YOUR RESUME TO YOUR APPLICATION (PDF OR WORD FORMAT) **   

Interview Process 

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

• Text Prescreen: Shortly after submitting your application, you may receive both a text message and email requesting you to complete 10 to 15 prescreen questions with either yes or no answers. The text message may arrive prior to the email. If you prefer to answer via computer or tablet, wait for the email. 

• Video Prescreen: If you are successful with your text screen, you will receive another communication to record a Video Prescreen. This is an online video activity using your phone, tablet, or computer; however, most candidates prefer using a computer or tablet.  

• Interviews: Some candidates will be invited to interview. If so, the recruiter will reach out to schedule. 

• Offers: Finalists from the interview will be contacted by a recruiter to discuss an offer for the job 

• Note: Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep yo