Quality Compliance Professional 2

Employment Type: Full-time

Position Overview

Humana Healthy Horizons in Virginia is seeking a Quality Compliance Professional 2 to join our caring community. This role is responsible for conducting audits and assessments to ensure adherence to organizational policies, regulatory requirements, and established quality standards. The position supports continuous improvement efforts by identifying areas of risk or non-compliance and recommending corrective actions. This role'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.
• Plan, schedule, and perform quality compliance audits across various external provider types to identify areas of risk or noncompliance and recommend corrective action plans.
• 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 the National Committee for Quality Assurance (NCQA), Centers of Medicare & Medicaid Services (CMS), and Department of Medical Assistance Services (DMAS) standards.
• Analyze audit findings to identify patterns, trends, and areas for improvement.
• Prepare detailed audit reports, including findings, recommendations, and follow-up actions.
• Provide guidance and training to staff on compliance and quality assurance best practices.
• Monitor progress on remediation plans and ensure timely closure of audit findings.
• 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.
• Maintain current knowledge of applicable laws, regulations, and industry standards.

Required Qualifications

• Must reside in the Commonwealth of Virginia.
• Bachelor’s degree or three (3) years of professional experience in quality compliance or quality improvement in healthcare.
• One (1) or more years of professional experience in medical audits and medical record reviews.
• 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 to perform 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

• 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.

Additional Information

Workstyle: This is a remote position with travel. Travel: Up to 25% to region-based providers to perform quality onsite audits and medical reviews.