Humana RN, Compliance Nurse 2 (Quality Assurance Audit) - Remote, FL in Deerfield Beach, Florida
The RN, Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The RN Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The RN Compliance Nurse 2 ensures mandatory reporting is completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals.
Perform pre-service denial and quality assurance audits and summarize findings for the clinical operational teams to initiate and identify needed corrective action plans.
Analyze authorizations and medical records in accordance with specified departmental policies and regulatory requirements.
Provide detail audit results which can include issues on absence of documentation, incorrect decision making, non-compliance with timeliness request, not using established criteria for decision making, or not following departmental processes.
Responsible for internal and external communications to obtain needed information and/or verify data related to the audit functions.
Recommend process changes or training opportunities related to audit trends to the clinical operational teams.
Coordinate special compliance projects and any additional tasks as determined by leadership.
Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
Follows established guidelines/procedures.
Unrestricted active RN license in the state of FL without current disciplinary action.
Prior clinical experience in an acute care, skilled or rehabilitation clinical setting.
Experience with Pre-service denials and quality assurance audits.
Excellent computer skills and ability to easily navigate multiple applications.
Strong communication skills, both verbal and written.
Ability to work independently under general instructions and with a team.
Must be passionate about contributing to an organization focused on continuously improving consumer experiences.
Must have a room in your home designated as a home office; away from high traffic areas where confidential information may be secured.
Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) High-speed DSL or cable modem internet connection for a home office.
BSN or Bachelor's degree in a related field.
Experience as a utilization management Auditor.
Experience in utilization management.
Ability to be licensed in multiple states without restrictions.
Health Plan experience working with large carriers.
Experience working with MCG guidelines.
Bilingual (English, Spanish) a plus.
- Work Days/Hours: Monday - Friday; 8am-5pm EST, with overtime as needed based on the needs of the business. Rotating on-call weekend coverage with others on the team will be required.
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
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