Hybrid Compliance Nurse – Medicaid

at Humana

• Job title: Compliance Nurse – Medicaid
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: $71,100 - $97,800 per year
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, United States

About the role

• Compliance Nurse reviewing Medicaid case management activities to ensure policy adherence. Analyzing data and conducting audits for compliance while supporting operational metrics and team success.

Responsibilities

• Ensures mandatory reporting completed.
• Complies, conducts, and summarizes compliance audits/reports to include deficiencies and risks.
• Collects, review records, summarizes issues and analyzes data daily, weekly, monthly, or as needed to assess outcome and operational metrics for the team and individuals to determine appropriate course of action.
• Audits CM medical records and operation for compliance.
• Proficiency in analyzing, tracking, and interpreting data trends, operational guidelines and procedures are adhered to.
• Ensures DMAS Cardinal Care Guidelines, NCQA, CMS, and Humana's Healthy Horizon's Policy and Procedures are followed.
• This is a mainly a virtual position, however, it may require occasional travel for meetings or audits to ensure accreditation is met.
• Ensures auditing is completed timely and communicated with leadership.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Other duties as assigned per CM or Quality leadership.

Requirements

• Must reside in the Commonwealth of Virginia or within a 40-mile radius from Virginia in a bordering state/district (Washington DC, MD, WV, KY, TN & NC).
• Bachelor's degree
• Active Registered Nurse license in the state of Virginia, or obtain a multi-state license a bordering contiguous state that participates in the enhanced licensure, (eNLC) without disciplinary action
• Minimum three, (3) years of experience in an MCO environment
• 2 yrs previous audit experience
• Minimum three, (3) years of nursing experience
• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment
• CMS, NCQA and DMAS guidelines
• Ability to work independently under general instructions and with a team
• Exceptional oral and written communication and interpersonal skills.

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave
• short-term and long-term disability
• life insurance and many other opportunities