Quality Compliance Nurse Professional 2

Employment Type: Full-time

Position Overview

Humana Healthy Horizons in Virginia is seeking a Quality Compliance Nurse Professional 2 to join our caring community and help us put health first. This role is focused on ensuring the quality and safety of patient care through conducting quality reviews and research to support quality assurance. The Quality Compliance Nurse Professional 2's work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

• Conduct medical records reviews to ensure proper documentation, coding, coordination of care and service for our members, and accurate reporting of outcomes.
• Collect and analyze data to develop process improvement strategies and/or corrective actions as needed.
• Review medical records for supplemental data and enter data into the supplemental data base.
• Conduct medical record audits and assessments to evaluate compliance with established standards and to ensure compliance with National Committee for Quality Assurance (NCQA), Centers of Medicare & Medicaid Services (CMS), and Department of Medical Assistance Services (DMAS) standards.
• Prepare for external audits and address any findings or corrective actions.
• Track and monitor compliance Quality Management Reviews (QMR) reporting requirements and documentation.
• Analyze clinical data and quality metrics to identify trends, areas for improvement, and compliance issues.
• Prepare reports for senior management and other functional areas.
• Work closely with clinical and administrative staff to promote best practices in quality care and ensure alignment with compliance goals.

Required Qualifications

• Must reside in the Commonwealth of Virginia.
• An active, unrestricted Licensed Practical Nurse (LPN) or a licensed Registered Nurse (RN) with an active, unrestricted license in the Commonwealth of Virginia.
• One (1) or more years of professional experience in medical audits and clinical reviews.
• One (1) or more years of experience working with quality in a fast-paced insurance or health care setting.
• Experience working with healthcare providers.
• Comprehensive knowledge of Microsoft Word, Excel, and PowerPoint.
• Excellent communication skills, both oral and written.
• Strong relationship-building skills.
• Ability to travel to region-based providers and members for face-to-face interviews, quality onsite audits, and medical reviews.
• This role is considered patient-facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

Preferred Qualifications

• BSN or bachelor’s degree in health administration or a related field.
• One (1) or more years of experience working directly with Healthcare Effectiveness Data and Information Set (HEDIS) measures and quality improvement initiatives measures.
• Three (3) years of managed care health plan experience.
• Knowledge of Humana's internal policies, procedures, and systems.
• Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read, and write in both languages without limitations and assistance.

Workstyle and Travel

• Workstyle: This is a remote position with travel.
• Travel: Up to 25% to region-based providers and members for face-to-face interviews, quality onsite audits, and medical reviews. You may be required to attend onsite team engagement meetings in Humana.

Company Information

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