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.
The Utilization Management Compliance Nurse 2 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.
- This role requires you to reside in KY or live within driving distance to attend meetings. If you reside less than 1 hour of Louisville, KY you will be expected to work from the Market office. (See additional information below)
Otherwise Work At Home is offered if you meet the WAH requirements as follows:
- Must have the ability to provide a high speMed 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) is required.
- Active Unrestricted RN license in the state of KY
- Must reside in the State of KY OR within driving distance of the Market Office in Louisville, KY OR in bordering counties of Kentucky
- Ability to be licensed in multiple states without restrictions
- 3 years varied nursing experience
- 1 year Utilization Management experience- and outline experience on Resume
- 1 year Compliance Auditing experience - and outline experience on Resume
- Must be proficient in utilizingMCG/Interqual Guidelines
- Health Plan experience working with large carriers
- Proficient with Microsoft Office products including Word, Excel and Outlook
- 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
- Previous Medicare/Medicaid experience a plus
- Previous experience or knowledge of NCQA accreditation requirements a plus
In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves. The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process. #ThriveTogetherInterview Process
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 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. Please be sure to describe your experience during this process. Scheduled Weekly Hours