[Remote] Quality Audit Professional at Humana

Kentucky, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

U.S. citizenship (Department of Defense Contract requirement)
Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services)
Not authorized to work in Puerto Rico per government contract; cannot be currently living in Puerto Rico
Active licensed RN in state of employment
3 years clinical RN experience
2 years of Utilization Review, Case Management, or Quality Management experience
Strong analytical skills, experience manipulating and interpreting data
Ability to work 7 - 4 p.m. E.T. or 8 - 5 p.m. E.T
Work at Home Requirements: minimum download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable or DSL suggested; satellite, cellular, microwave only if approved); work from dedicated space lacking interruptions to protect PHI/HIPAA; occasional travel to Humana offices for training/meetings may be required

Responsibilities

Analyzes and investigates quality issues, interpreting and independently determining appropriate courses of action
Supports Healthcare Quality Management Team in administering and implementing Clinical Quality Management Program (CQMP)
Collects and reviews records, summarizes issues, works with Medical Director as needed, and implements corrective actions as assigned
Coordinates case presentations and presents to Patient Safety Peer Review Committee (PSPRC)
Audits quality cases for compliance and participates in department projects as available
Reviews medical records, creates case summaries, and presents potential quality issue (PQI) cases to Medical Director for review
Provides assistance to Medical Directors to ensure corrective action plans (CAPs) are developed and implemented; monitors CAP for timeliness and enters data into Provider Trending Database per Policy and Procedure
Monitors cases in Clinical Quality Management Database (CQMD) for accuracy, timeliness of completion, and documentation
Participates in case presentation and discussion at PSPRC meetings
Reviews PQIs from all sources to determine need for medical record review
Participates in departmental projects such as focused reviews as available

Skills

Key technologies and capabilities for this role

Quality AuditingMedical Record ReviewCorrective Action PlansCase SummarizationPeer Review PresentationHealthcare Quality ManagementClinical Quality Management ProgramProvider Trending DatabaseCQMD

Questions & Answers

Common questions about this position

What are the required qualifications for the Quality Audit Professional role?

Candidates must be U.S. citizens, receive interim government security clearance, hold an active RN license in the state of employment, have 3 years of clinical RN experience, 2 years in Utilization Review, Case Management, or Quality Management, strong analytical skills with data experience, and be able to work 7-4 p.m. ET or 8-5 p.m. ET.

Is this a remote position, and what are the work-from-home requirements?

The role includes work at home requirements with a minimum download speed of 25 Mbps and upload speed of 10 Mbps recommended, using wireless, wired cable, or DSL; satellite is not suggested. HGB cannot hire candidates currently living in Puerto Rico due to the government contract.

What are the preferred qualifications for this position?

Preferred qualifications include accreditation experience (URAC, NCQA or JCAHO) and Quality Management experience.

What is the salary or compensation for the Quality Audit Professional role?

This information is not specified in the job description.

What makes a strong candidate for this Quality Audit Professional position?

A strong candidate will have an active RN license, relevant clinical and quality management experience, strong analytical skills, U.S. citizenship for security clearance, and the ability to work Eastern Time hours while meeting home internet requirements.

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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