Humana
Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
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.
Active Registered Nurse license in a state that is part of the Enhanced Nursing Licensure Compact (eNLC) compact without disciplinary action ability to obtain additional state licensures without restrictions Intermediate or better proficiency using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment Minimum of three, (3), years varied clinical nursing experience. Minimum of one, (1), year of experience auditing and/or performing case management or utilization management chart reviews Ability to work independently under general instructions and with a team Workstyle: Remote work at Home Location: Must reside in a state that is part of the Enhanced Nursing Licensure Compact (eNLC) Schedule: Typically, Monday through Friday 8:00 – 5:00pm Eastern Time Flexible scheduling upon leader approval Travel: 1 to 2 time annually to the local market office as needed for meetings Work at Home Guidance To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested Satellite, cellular and microwave connection can be used only if approved by leadership Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Preferred Qualifications: Bachelor's, BSN 2 years of behavioral health experience; working knowledge of ASAM criteria Health Plan experience working with large carriers Previous Medicare/Medicaid experience a plus Previous experience in utilization management, case management, discharge planning and/or home health or rehab Certification in Case Management a plus (CCM) Experience working with MCG or InterQual guidelines MCG Certification
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The 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.
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