Compliance Registered Nurse

Virginia, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess an active Registered Nurse license within an Enhanced Nursing Licensure Compact (eNLC) state without disciplinary action and be able to obtain additional state licenses without restrictions. A minimum of three years of varied clinical nursing experience and at least one year of utilization management experience using MCG Guidelines are required. Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint), navigating multiple systems, and basic technical troubleshooting in a remote environment is necessary. A BSN, experience in behavioral health utilization management, health plan work with large carriers, Medicare/Medicaid experience, Case Management Certification (CCM), and NCQA experience are preferred qualifications. Candidates must reside in an eNLC state and be available to work Thursday through Sunday, 7:30 AM - 6:30 PM Eastern, including rotating holidays.

Responsibilities

The Compliance Nurse reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations, and to detect fraud, waste, and abuse. This role involves performing mandatory reporting, conducting and summarizing compliance audits, and collecting and analyzing data to assess operational metrics. The nurse will interpret changes in legislation, review denial letters for compliance with accreditation and state contractual requirements, and make decisions regarding work methods with minimal direction.

Skills

Registered Nurse

Utilization Management

MCG Guidelines

Microsoft Office Suite

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Data Analysis

Auditing

Compliance

Fraud Detection

Waste Detection

Abuse Detection

Behavioral Health Utilization Management

Medicare

Medicaid

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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