Compliance UM Nurse (Wed - Sun)

About the role

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 role follows a four-day, 10-hour shift schedule within a Wednesday through Sunday work week.

Responsibilities

• Interpret and independently determine appropriate courses of action for utilization management activities.
• Collect and analyze data daily, weekly, monthly, or as needed to assess outcomes and operational metrics for the team and individuals.
• Understand department, segment, and organizational strategy and operating objectives, including their linkages to related workstreams.
• Follow established guidelines, regulatory turnaround times, and procedures for processing QIO fast track appeals and expedited authorization requests.

Requirements

• Licensed Registered Nurse (RN) in a compact state with no disciplinary action.
• Must have valid compact license or reside in a compact state and be eligible to upgrade to compact licensure.
• Three (3) or more years of consecutive UM experience for a health plan OR two (2) or more years of consecutive UM auditing experience in a traditional Quality or Compliance role at a health plan OR one (1) or more years of home health utilization management experience for a health plan.
• Effective telephonic and virtual communication skills.
• Comprehensive knowledge of Microsoft Word, Outlook and Excel.
• Able to work independently under general instructions and within a team.

Qualifications

• Required Qualifications: Licensed Registered Nurse (RN) in a compact state with no disciplinary action. Three (3) or more years of consecutive UM experience for a health plan OR two (2) or more years of consecutive UM auditing experience in a traditional Quality or Compliance role at a health plan OR one (1) or more years of home health utilization management experience for a health plan.
• Preferred Qualifications: Current member of the One Home / Home Solutions UM Team who has been in their current position for 12+ months, Bachelor’s degree in nursing or related field, clinical experience in a home health and/or Skilled Nursing Facility setting, clinical experience working QIO appeals, expedited request reviews and/or compliance, Health Plan experience.

Skills

Required skills include effective telephonic and virtual communication skills, comprehensive knowledge of Microsoft Word, Outlook and Excel, and the ability to work independently under general instructions and within a team. Preferred skills include a Bachelor’s degree in nursing or related field, clinical experience in a home health and/or Skilled Nursing Facility setting, clinical experience working QIO appeals, expedited request reviews and/or compliance, Health Plan experience.

Benefits

This position offers a flexible schedule of Monday to Sunday, between 8 am and 8 pm EST with occasional overtime. This position follows a 4-day workweek consisting of ten-hour shifts, available schedules include: Wednesday - Saturday or Thursday - Sunday. 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 is 25mbs download x 10mbs upload is required. Check your internet speed at www.speedtest.net. A dedicated office space lacking ongoing interruptions so you can meet productivity requirements, and to protect member PHI / HIPAA information. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

About Us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.