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

Humana Healthy Horizons in Virginia is seeking Quality Compliance Professionals who will be responsible for conducting audits and assessments to ensure adherence to organizational policies, regulatory requirements, and established quality standards. This position supports continuous improvement efforts by identifying areas of risk or non-compliance and recommending corrective actions. The Quality Compliance Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Quality Compliance 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.  

• Plans, schedules, and performs quality compliance audits across various external provider types to identify areas of risk or noncompliance and recommend corrective action plan.
• 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 the National Committee for Quality Assurance (NCQA), Centers of Medicare & Medicaid Services (CMS) and Department of Medical Assistance Services (DMAS) standards.
• Analyze audit findings to identify patterns, trends, and areas for improvement.
• Prepares detailed audit reports, including findings, recommendations, and follow-up actions.
• Provides guidance and training to staff on compliance and quality assurance best practices.
• Monitors progress on remediation plans and ensure timely closure of audit findings.
• 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.
• Maintains current knowledge of applicable laws, regulations, and industry standards.

Use your skills to make an impact
 

Required Qualifications

• Must reside in the Commonwealth of Virginia.
• Bachelor’s degree or three (3) years of professional experience in quality compliance or quality improvement in healthcare.
• One (1) or more years of professional experience in medical audits and medical record reviews.
• 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 to perform 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

• 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 to perform 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).
• 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) te