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

The Senior Compliance Nurse reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Senior Compliance Nurse work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

 The Senior Compliance Nurse is responsible for maintaining, updating and submitting clinical coverage policies for the Kentucky Medicaid market. Additionally, this role is responsible for completing audits of records to ensure compliance with process and expectations. This role also helps to support compliance and contractual auditing and data requests from Kentucky Department for Medicaid services.

Use your skills to make an impact
 

Required Qualifications

• Unrestricted Registered Nurse license in the state of Kentucky or have a compact license
• Bachelor's degree or 5 years or more relevant experience in lieu of degree
• 5 + years of technical experience with the ability to navigate multiple screens and databases with proficiency with Microsoft Office (Excel, Word, Power Point, Visio) and other virtual platforms i.e. zoom and Teams
• 2 years Medicare/Medicaid or Health Plan Experience in Utilization Management
• Great Communication Skills -Written and Verbal
• 2 years exp with compliance auditing with knowledge of NCQA UM Requirements
• Experience with reviewing data to identify trends, process gaps and/or Associate learning opportunities
• Experience with leading process change initiatives
• Experience utilizing MCG
• Must be available to attend meetings in the Market Office – the expectation is to reside in KY or a county that borders the state of KY and willingness to report to the office for occasional meetings

 Preferred Qualifications

•  MCG Certification
• Experience with creating data presentations in the form or graphs/charts/graphics
• Presentation skills on reporting
• Proficient working with CGX, QuickBase
• Project Management Experience
• Bilingual in any language you are fluent in reading and writing in addition to the English language

 

Additional Information

• Schedule: Monday to Friday from 8 am to 5 pm Eastern Standard Time Zone (regardless of where you reside)
• Work Location: KY or a county that borders the state of KY and willingness to report to the office for occasional meetings

Work At Home Requirements

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

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees 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 employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Interview Format

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

SSN Alert Statement: Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skill