Quality Compliance Nurse (Maternal-Child Health/EPSDT)

Position Overview

• Location Type: Remote
• Job Type: Full time
• Salary: Not specified

Humana Healthy Horizons in Virginia is seeking a Quality Compliance Nurse Professional 2 (Maternal-Child Health/EPSDT) to join our caring community. This role focuses on ensuring timely access to high-quality maternal and postpartum care, as well as Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services for individuals under twenty-one years old. The position also involves promoting family planning services and preventive health strategies within the Medicaid program.

Requirements

• Must reside in the Commonwealth of Virginia.
• Active, unrestricted licensed Practical Nurse (LPN) or a licensed Registered Nurse (RN) with an active, unrestricted license in the Commonwealth of Virginia.
• Two (2) or more years of experience working in Maternal Child Health (MCH) or Early Periodic Screening diagnosis and Treatment (EPSDT).
• Two (2) or more years of professional experience in Medicaid programs, managed care case management, quality improvement in healthcare, or pediatric office operations.
• Intermediate proficiency in Microsoft Programs (Word, Excel, and PowerPoint).
• Excellent communication skills, both oral and written.
• Ability to work independently under general instructions, be self-directed, and motivated.

Responsibilities

• Conduct telephonic outreach to encourage enrollees to access preventative care and assist with appointment and transportation scheduling.
• Review EPSDT services, assessments, and HEDIS data to identify care gaps and implement targeted interventions to increase utilization of well-child visits, exams, screenings, and services.
• Conduct medical record and/or claims reviews of providers serving children under twenty-one to ensure appropriate treatment in children and adolescents.
• Identify and coordinate services for member needs, specific to Maternal-Child Health (MCH) and Periodic Screening, Diagnosis, and Treatment (EPSDT).
• Coordinate with community partners to support MCH and EPSDT services, including developing and implementing population health programs and community events.
• Review coverage for all members under twenty-one to ensure appropriateness of benefits as described under the medically necessary treatment for EPSDT benefit.
• Collaborate with Provider Relations personnel to support provider education efforts related to MCH and EPSDT.
• Ensure compliance with state and federal requirements and NCQA standards pertaining to MCH and EPSDT.
• Participate in quality committees and quality improvement meetings with internal and external partners to advise on MCH and EPSDT performance and related quality initiatives.

Preferred Qualifications

• Prior experience working with healthcare quality metrics in a fast-paced insurance or healthcare setting.
• Previous experience with Clinical Auditing or Clinical Review.
• Prior experience working with healthcare providers.
• Knowledge of HEDIS/Stars/CMS/Quality metrics.
• Detail-oriented and comfortable working with tight deadlines in a fast-paced environment.
• Bilingual or Multilingual (English/Spanish, Arabic, Vietnamese, Amharic, Urdu, or other) with the ability to speak, read, and write in both languages without limitations or assistance.

Additional Information

• This is a remote position with minimal travel.
• Travel: Up to 10% to attend onsite team engagement meetings.