Compliance Nurse 2

Position Overview

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

• Ensures mandatory reporting is 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.

Required Qualifications

• Active Registered Nurse license in a state that is part of the Enhanced Nursing Licensure Compact (eNLC) compact without disciplinary actionability to obtain additional state licensures without restrictions.
• Intermediate or better 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.
• Minimum of three (3) years varied clinical nursing experience.
• Minimum of one (1) year of experience auditing and/or performing case management or utilization management chart reviews.
• Ability to work independently under general instructions and with a team.

Preferred Qualifications

• Bachelor's, BSN
• Health Plan experience working with large carriers
• Previous Medicare/Medicaid experience a plus
• 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
• MCG Certification

Additional Information

• Employment Type: Full time
• Workstyle: Remote work at Home
• Location: Must reside in a state that is part of the Enhanced Nursing Licensure Compact (eNLC).
• Schedule: Typically, Monday through Friday 8:30 AM – 6:00 PM Eastern Time. Flexible scheduling upon leader approval.
• Travel: 1 to 2 times annually to the local market office as needed for meetings.

Work from 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 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.

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Modern Hire Voice 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. If you are selected for a first-round interview, you will 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 in a Modern Hire Voice interview. In this interview, you will listen to a set of interview questions.