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

The RN, Compliance Nurse 2, Quality Assurance Auditor reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse.

The RN, Compliance Nurse 2, Quality Assurance Auditor ensures mandatory reporting is completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals.

• Perform pre-service denial and quality assurance audits and summarize findings for the clinical operational teams to initiate and identify needed corrective action plans

• Makes necessary revisions and edits to member pre-service denial letters prior to mailing to ensure compliance with Medicare requirements

• Analyze authorizations and medical records in accordance with specified departmental policies and regulatory requirements

• Provide detail audit results which can include issues on absence of documentation, incorrect decision making, non-compliance with timeliness request, not using established criteria for decision making, or not following departmental processes

• Responsible for internal and external communications to obtain needed information and/or verify data related to the audit functions

• Recommend process changes or training opportunities related to audit trends to the clinical operational teams

• Coordinate special compliance projects and any additional tasks as determined by leadership

Use your skills to make an impact
 

Required Qualifications

• Current Unrestricted Florida RN license or Compact RN License the state where you reside

• Experience with Utilization Management and Quality assurance audits

• Clinical experience in an Acute Care

• Proficiency in Microsoft Office Products Word, Excel, and Power Point

​Preferred Qualifications

• BSN or Bachelor's degree in a related field.

• Bilingual (English, Spanish)

• Experience as a utilization management Auditor

• Health Plan experience working with large carriers

• Experience working with MCG/Interqual guidelines

• Microsoft Outlook

• Excellent computer skills and ability to easily navigate multiple applications

• Skilled and/or Rehabilitation Clinical setting

Additional Information

• Work Days/Hours: Monday - Friday; 8am-5pm EST, with Overtime as needed based on the needs of the business.

• Rotating weekend coverage (with a day off during the week) with others on the team will be required.

• Travel to Market office with advanced notice for meetings and/or planned work functions.

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.  If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided.  Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriat