Responsibilities

The Senior Quality Compliance Professional will conduct and manage medical records reviews to ensure proper documentation, coding, and coordination of care, and accurately report outcomes. They will collect and analyze data to develop process improvement strategies and corrective actions, review medical records for supplemental data, enter data into a supplemental database, and conduct medical record audits and assessments to evaluate compliance with standards set by NCQA, CMS, and DMAS. The role involves preparing for external audits, addressing findings, developing and implementing quality assurance initiatives, tracking and monitoring CI and QMR reporting, analyzing clinical data and quality metrics, preparing reports, assisting in policy development, and providing leadership through coaching and mentoring of a team. Additionally, the professional will travel to providers and members for interviews and audits, and participate in Humana’s TB screening and driver safety programs.