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

Humana Healthy Horizons in Virginia is seeking a Quality Compliance Nurse Professional 2 who will be focused on ensuring quality and safety of patient care. They will conduct quality reviews and research to support quality assurance. The Quality Compliance Nurse Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Quality Compliance Nurse Professional 2 will conduct medical records reviews to ensure proper documentation, coding, coordination of care and service for our members as well as 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.
• Tracks and monitors compliance 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.
• Works closely with clinical and administrative staff to promote best practices in quality care and ensure alignment with compliance 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.  
• One (1) or more years of professional experience in medical audits and clinical reviews.
• One (1) or more years of experience working with quality in a fast-paced insurance or health care 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-based providers and members for face-to-face interviews, quality onsite audits and medical reviews. You may be required to attend onsite team engagement meetings in Humana Healthy Horizons, Glen Allen, VA office location.
• Typical Workdays/Hours: Monday – Friday; 8:00am -5:00pm, Eastern Standard Time (EST).
• Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

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