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

Humana Healthy Horizons in Virginia is looking for a Quality Compliance Nurse Professional 2 (Maternal-Child Health/EPSDT) who will collaborate with all departments to ensure timely access of the delivery of high-quality maternal and postpartum care and Early Periodic Screening, Diagnosis, and Treatment(EPSDT) services for individuals under the age of twenty-one years, including the promotion of family planning services and preventive health strategies. The Quality Compliance Nurse Professional 2 (Maternal-Child Health/EPSDT) works to ensure that children enrolled in Humana Healthy Horizon in Virginia Medicaid under the EPSDT program receive necessary preventative care, screenings, and treatments. They work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

• Conducts telephonic outreach to encourage enrollees to access preventative care and assist with appointment and transportation scheduling as necessary.
• Reviews EPSDT services and assessments and HEDIS data to identify gaps in care and targeted interventions to increase utilization of well-child visits, exams, screenings and services.
• Conducts medical record and/or claims reviews of providers working with children under the age of twenty-one to ensure experience in addition treatment in children and adolescents.
• Identifies and coordinates services for identified member needs, specific to Maternal-Child Health (MCH) and Periodic Screening, Diagnosis, and Treatment (EPSDT).
• Coordinates with community partners to support the delivery of MCH and EPSDT services, including development and implementation of population health programs and community events.
• Conducts reviews of coverage for all members under the age of twenty-one to ensure appropriateness of benefits as described under the medically necessary treatment for EPSDT benefit.
• Collaborates with Provider Relations personnel to support Provider education efforts related to MCH and EPSDT.
• Ensures compliance with state and federal requirements and NCQA standards that pertain to MCH and EPSDT.
• Participates as needed in quality committees and quality improvement related meetings with internal and external partners to advise on MCH and EPSDT performance and related quality initiatives.

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.  
• Two (2) or more years' experience working in Maternal Child Health (MCH) or Early Periodic Screening diagnosis and Treatment (EPSDT).
• Two (2) or more years' professional experience in Medicaid programs, managed care case management, quality improvement in healthcare or pediatric office operations.
• Intermediate proficiency in Microsoft Programs specifically, Word, Excel and PowerPoint.
• Excellent communication skills, both oral and written.
• Ability to work independently under general instructions, self-directed and motivated.

Preferred Qualifications

• Prior experience working with healthcare quality metrics in a fast past insurance or
  health care setting.
• Previous experience working with Clinical Auditing or Clinical Review.
• Prior experience working with healthcare providers.
• Knowledge of HEDIS/Stars/CMS/Quality.
• Detail orientated and comfortable working with tight deadlines in a fast-paced environment.
• 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 minimal travel.
• Travel: Up to 10% to attend onsite team engagement meetings in Humana Healthy Horizons, Glen Allen, VA office location and community events throughout Virginia.  
• 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.

Work from Home Internet Statement<