Risk Management Professional 2 (Licensed Nurse Required)

About the role

The Risk Management Professional 2 leads and executes quality audits within the CenterWell Utilization Management (UM) program, ensuring compliance with regulatory requirements, including CMS and NCQA standards.

Responsibilities

• Conduct comprehensive quality audits of UM activities to ensure adherence to regulatory standards (CMS, NCQA) and organizational policies
• Evaluate clinical decision-making and appropriate application of criteria across inpatient, outpatient, home health, and post-acute services
• Leverage Power BI to develop, maintain, and interpret dashboards reporting audit outcomes, performance trends, and risk areas
• Utilize Power Apps to support audit workflows, tracking, and data collection processes
• Analyze audit results to identify risks, trends, and patterns, and clearly communicate findings to leadership
• Perform root cause analysis to determine drivers of opportunities, inconsistencies, and compliance gaps
• Demonstrate strong familiarity with clinical criteria sources, including: Medicare Manuals, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), coverage policies, MCG guidelines
• Support program audits (CMS, NCQA) by contributing clinical insight, validating documentation, and ensuring audit readiness from a regulatory and research-based perspective
• Collaborate with clinical, operational, and compliance teams to drive quality improvement initiatives based on audit findings
• Translate complex data into actionable insights and recommendations for stakeholders
• Present audit findings, risks, and trend analyses confidently to leadership and cross-functional teams

Requirements

• Active, unrestricted Registered Nurse (RN)
• Extensive experience in utilization management, clinical auditing, and/or quality assurance
• Strong knowledge of CMS, NCQA, and regulatory/accreditation requirements
• Deep understanding of clinical criteria and coverage guidelines (Medicare manuals, NCDs, LCDs, MCG, etc.)
• Demonstrated experience identifying audit risks, trends, and root causes
• Experience supporting or participating in regulatory program audits (CMS, NCQA)
• Strong analytical and critical thinking skills with ability to interpret and act on data
• Exceptional attention to detail and commitment to quality outcomes
• Ability to communicate complex findings clearly and influence stakeholders

Preferred Qualifications

• Prior experience in a dedicated auditor or quality oversight role
• Experience working in healthcare environments across inpatient, outpatient, home health, and post-acute care
• Familiarity with audit tracking tools, reporting systems, and dashboards
• Experience translating data into reporting and insights

Work at Home Requirements

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.

Travel

While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

$65,000 - $88,600 per year

Description Of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being.

About CenterWell, a Humana company

About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.