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DescriptionThe Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Compliance Nurse 2 will create and maintain audit tools and periodic training of the team.ResponsibilitiesThe Compliance Nurse 2 ensures mandatory reporting 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. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures in addition to creating and maintaining team audit tools and training events.Required QualificationsActive Registered Nurse, RN, license in South Carolina without restrictions
Ability to be licensed in multiple states without restrictions
Minimum three, (3), years varied clinical nursing experience
General knowledge of managed care and Medicaid experience
Intermediate to Advanced knowledge using Microsoft Office Programs specifically Teams, Excel, PowerPoint, Outlook and Word
Intermediate to Advanced ability navigating through new systems/platforms, and an ability to troubleshoot and resolve general technical difficulties.
Ability to work independently under general instructions and with a team
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Workstyle: Remote work at homeLocations: Eastern Time Zone:Pennsylvania, Kentucky, Georgia, Florida, South Carolina, North Carolina Ohio, Virginia, West Virginia, Maryland, New Jersery, New York, Rhode Island, Connecticut, Delaware, Massachusetts, New Hampshire, Vermont, and Maine
Hours: 8:00 AM - 5:30 PM EasternTravel: May travel 5-10% for quarterly and annual meetingsRemote at Home Requirements:Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work
Must have accessibility to hardwired high speed internet with minimum speeds of 25Mx10M for a home office (Wireless and Satellite are prohibited)
Preferred QualificationsBSN
Health Plan experience working with large carriers
Previous experience in utilization management, case management, discharge planning and/or home health or rehab
Certification in Case Management a plus (CCM)
Experience working with MCG or Interqual guidelines
Prior or current experience with the following systems: CGX, Veritas, and Emme,
Additional InformationInterview FormatAs part of our hiring process for this opportunity, we will be using an exciting screening and interviewing technology called Modern Hire to enhance our hiring and decision-making ability. We use this technology to gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
You will be able to respond to the recruiters preferred response method via text, video or voice technologies If you are selected for a screen, you may receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate. You should anticipate this screen to take about 15 to 30 minutes. Your recorded screen will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Humana Covid PracticesHumana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
Scheduled Weekly Hours40
Full-time