[Remote] QA External LTSS Oversight Professional at Humana

Michigan, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Bachelor’s degree in social work or nursing (unlicensed)
A minimum of 2 years’ experience in LTSS
Proficient with Microsoft Office products including Word, Excel, Power Point, and Outlook
Previous experience with Managed Care Organization
Ability to work independently under general instructions and with a team
Exceptional oral and written communication and interpersonal skills
Reside in the state of Michigan or within 40 miles of the border in Indiana or Ohio
Ability to travel as needed

Responsibilities

Reviews LTSS contractor documentation and performance to ensure compliance with contract scope of work, and state and federal regulations
Ensures adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse
Understands department, segment, and organizational strategy and operating objectives
Complies, conducts, and summarizes compliance audits/reports to include deficiencies and risks
Collects, reviews records, summarizes issues and analyzes data daily, weekly, monthly, or as needed to assess outcome and operational metrics
Conducts inter-rater reliability audits for multiple vendor activities
Analyzes, tracks, and interprets data trends, operational guidelines and procedures
Ensures MDHHS, NCQA, CMS, and Humana’s Healthy Horizon’s Policy and Procedures are followed
Ensures auditing is completed timely and communicated with leadership
Makes decisions regarding own work methods, occasionally in ambiguous situations
Other duties as assigned per CLTSS leadership team

Skills

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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