Compliance Nurse (Central Region)

The 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.

Responsibilities

Compliance Nurse (Central Region)

The Compliance Nurse 2 ensures that processes and compliance regulations are followed. Analyzes data daily, weekly, monthly or as needed to assess outcome and provide education as needed. 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.

• Work with QIO Appeals letters
• Potential for cross-training in other areas
• Audit FER cases to ensure processes are followed
• Works with automated Letter BOT
• Answer process questions

Required Qualifications

• Ability to work independently under general instructions
• 2 or more years of Utilization management nursing experience
• Excellent communication skills both verbal and written
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Excellent presentation skills
• Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action
• Proficient with Microsoft Office products including Word, Excel, PowerPoint and Outlook

Preferred Qualifications

• Previous auditing experience in a clinical capacity
• 2 years of acute care hospital experience
• Previous Medicare/Medicaid experience
• Experience working with MCG or Medicare guidelines
• Bachelor’s degree in nursing (BSN)
• MCG Certification a plus

Work-At-Home Requirements

• 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
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job
• 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
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information

• Hours are: Monday-Friday 8am-5pm or 8:30am-5pm CST, overtime and weekend work may be required based on a business need
• A holiday rotation is required for this role

#LI-Remote

Scheduled Weekly Hours

40