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: 1 to 2 times annually to the local market office as needed for meetings.
Core Workdays & Hours: Typically, Monday – Friday 8:00am – 5:00pm Eastern Standard Time (EST). Flexible scheduling upon leader’s approval.
Interview Format
As part of our hiring process, we will be using exciting interviewing technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers with 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 the next round of interviews.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours
40Pay 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 skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.About us
Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.