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

Humana Healthy Horizons in Virginia is seeking a Senior Quality Compliance Professional who will be is a key leader focusing on ensuring quality and safety of patient care and will provide oversight of quality reviews and research to support quality assurance and implementation of quality control process. The Senior Quality Compliance Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. They exercise considerable latitude in determining objectives and approaches to assignment and influences the department’s strategy.

The Senior Quality Compliance Professional will conduct and manage medical records reviews to ensure proper documentation, coding and coordination of care and service for our members and accurate reporting of outcomes.  

• Collects and analyzes data to develop process improvement strategies and/or corrective actions as needed.
• Reviews medical records for supplemental data and enter data in supplemental data base.
• Conducts medical record audits and assessments to evaluate compliance with established standards and to ensure compliance with National Committee for Quality Assurance (NCQA), Centers of Medicare & Medicaid Services (CMS) and Department of Medical Assistance Services (DMAS) standards.
• Prepares for external audits and addresses any findings or corrective actions.
• Develops and implements quality assurance initiatives aimed at improving patient care and outcomes and monitors the effectiveness of these programs and make necessary adjustments.
• Tracks and monitors compliance with Critical Incident (CI) and Quality Management Reviews (QMR) reporting requirements and documentation.
• Analyzes clinical data and quality metrics to identify trends, areas for improvement, and compliance issues.
• Prepares reports for senior management and other functional areas.
• Assists in the development and revision of organizational policies and procedures related to quality and compliance.
• Works closely with clinical and administrative staff to promote best practices in quality care and ensure alignment with compliance goals.
• Provides leadership through coaching and mentoring of a small team of quality reviewers and audits, setting and tracking both team and individual goals.

Use your skills to make an impact
 

Required Qualifications

• Must reside in the Commonwealth of Virginia.
• An active, unrestricted licensed Practical Nurse (LPN) or a licensed Registered Nurse (RN) with an active, unrestricted license in the Commonwealth of Virginia.  
• Three (3) years of professional experience in medical audits and clinical reviews.
• Two (2) or more years of experience working with quality in a fast-paced insurance or health care setting.
• Previous leadership experience in a clinical or nonclinical setting.
• Experience working with healthcare providers.
• Comprehensive knowledge of Microsoft Word, Excel and PowerPoint.
• Excellent communication skills, both oral and written.
• Strong relationship building skills.
• Ability to travel to region-based providers and members for face-to-face interviews, quality onsite audits and medical reviews.
• This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

Preferred Qualifications

• BSN or bachelor’s degree in health administration or a related field.
• One (1) or more years of experience working directly with Healthcare Effectiveness Data and Information Set (HEDIS) measures and quality improvement initiatives measures.
• Three (3) years of managed care health plan experience.
• Knowledge of Humana's internal policies, procedures and systems.
• Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations and assistance. See “Additional Information” section for more information.  

Additional Information

• Workstyle: This is a remote position with travel.
• Travel: Up to 25% to region-b