Job Description

Description

The 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 Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Compliance Nurse 2- Auditor ensures mandatory reporting 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. 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.

* 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.

Required Qualifications

* RN with active license in FL, no 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
* Work At Home requirements: 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; A dedicated space with a door that locks preventing ongoing interruptions
* Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

* 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
* Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. See Additional Information on testing

Additional information

* Schedule: Mon-Fri, 8am-5pm EST, with overtime as needed based on the needs of the business. Rotating on-call weekend coverage (with other associates within the team) will be required.
* Training: remotely
* If Bilingual - Language Proficiency Testing: Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.
* Work Location (Address): Work At Home (Remotely) FL only. Office: 11430 NW 20th St 300 Miami, Fl 3172

Scheduled Weekly Hours

40