Quality Compliance Professional

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 reside in the Commonwealth of Virginia and possess a Bachelor's degree or three years of professional experience in healthcare quality compliance or improvement. One or more years of experience in medical audits and record reviews, along with experience working with healthcare providers and comprehensive knowledge of Microsoft Word, Excel, and PowerPoint are required. Excellent oral and written communication, strong relationship-building skills, and the ability to travel up to 25% to region-based providers for onsite audits and medical reviews are also necessary. A valid state driver's license and personal vehicle liability insurance are mandatory, and candidates may be subject to TB screening.

Responsibilities

The Quality Compliance Professional will conduct medical record reviews for documentation, coding, and service coordination, ensuring accurate outcome reporting. They will plan and perform quality compliance audits on external providers to identify risks and recommend corrective actions, analyzing findings to identify trends and areas for improvement. Responsibilities include preparing detailed audit reports, providing guidance and training on compliance best practices, monitoring remediation plan progress, and preparing reports for senior management. The role involves working closely with clinical and administrative staff to promote quality care and maintaining current knowledge of relevant laws and industry standards.

Skills

Quality Assurance

Compliance

Auditing

Medical Records Review

NCQA Standards

CMS Standards

DMAS Standards

Risk Assessment

Corrective Action Plans

Data Analysis

Report Writing

Training

Process Improvement

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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