Company Description

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.

Job Description

The Quality Compliance Nurse helps in providing an accurate, timely, and compliant abstraction of medical records to meet HEDIS measurement and reporting requirements as outlined by the National Committee for Quality Assurance (NCQA). The Quality Compliance Nurse Professional 2 performs clinical reviews and supports the staff involved in HEDIS hybrid season review.

Requirements

Required Qualifications Registered Nurse (RN) license Associate's or Bachelor's Degree Strong clinical background preferably any acute setting such as hospital, physician office practice, or short/long term care institution Knowledge of chart review/chart extraction Detail orientated and comfortable working with tight deadlines in a fast-paced environment Strong analytical skills, able to manipulate and interpret data Organizational and prioritization skills Critical thinking, multitasking and flexible in handling various assignments Strong oral /written communication and presentation skills Comprehensive knowledge of Microsoft Office Word, Excel, PowerPoint, Outlook, Teams and Zoom Preferred Qualifications Electronic Health Records (EHR) experience Knowledge of HEDIS/Stars/CMS/Quality Previous quality or process improvement experience in any acute setting such as hospital or physician office practice, and long-term care institution. Ability to work independently under general instructions, self-directed and motivated

Responsibilities

The Quality Compliance Nurse works to gain more information about members 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 such as: Medical record abstraction for HEDIS hybrid measures. Clinical validation of data elements (e.g., BMI, immunization records, cancer screenings). Conducting peer-reviews to ensure compliance with NCQA guidelines and organizational standards Conducting in-depth research on clinical events as assigned (Research Process)

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