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Humana Healthy Horizons is seeking a Senior Compliance Nurse Professional who ensures utilization management and complex case management processes and procedures meet compliance with Centers for Medicare/Medicaid (CMS), each state Medicaid contractual requirements, and NCQA requirements. The Senior Compliance Nurse Professional 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 Professional develops and implements compliance policies and procedures. Roles and responsibilities include:

• Research compliance issues and recommends changes that assure compliance with CMS, NCQA, and state contract obligations.

• Develop and implement process improvement initiatives and strategies with Quality and Compliance team to close compliance issues/gaps and mitigate risk, with focus on NCQA accreditation and state specific contractual requirements.

• Maintains relationships with Medicaid market Regulatory Compliance Professionals to ensure state specific contractual requirements are met regarding utilization management, complex case management, and clinical compliance.

• Create and maintain National Medicaid Compliance policies and procedures to ensure consistency across the Medicaid organization and decrease compliance risk.

• Create and maintain National Medicaid Policies for CCM and UM documentation to support NCQA requirements.

• Influences utilization management, complex case management, and clinical compliance department’s strategies and processes.

• Coordinates implementation and compliance with corrective action plans, as needed.

• Create new Medicaid market utilization management letters for state readiness review and submission based on contractual requirements.

• Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction.

• Exercises considerable latitude in determining objectives and approaches to assignments.

Use your skills to make an impact
 

Required Qualifications

• Active Registered Nurse with a compact license and no disciplinary action.

• Ability to obtain additional state licensures without restrictions in states that do not participate in the compact licensing agreement.

• 3+ years of varied clinical nursing experience.

• 1+ year experience as a Subject Matter Expert in Medicaid Utilization and/or Complex Case Management.

• Knowledge/understanding of laws and regulations governed by the Department of Insurance, CMS, NCQA, and multiple Medicaid states.

• Successful experience leading small to large sized complex projects.

• Intermediate to advanced proficiency using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment.

Preferred Qualifications

• Bachelor’s degree.

• Experience auditing and/or performing case management or utilization management chart reviews.

• Experience with metrics and reporting.

• Behavioral Health experience.

• Lean Six Sigma certification.

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 with a bi-weekly payment for their internet expense

• Humana will provide Home or Hybrid Home/Office associates 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

Additional Information

• Workstyle: Remote, work from home.

• Location: Must reside in a state that is part of the Enhanced Nursing Licensure Compact (eNLC).

• Preferred Locations: AL, FL, GA, IN, KY, LA, NC, OH, OK, SC, TN, TX, VA.

• Travel: