Manager, Quality Assurance (LTSS)

Humana; United States; Remote; USD 90,000 - 115,000; Full time

Job summary

Humana seeks a Manager, Quality Assurance for the External LTSS Oversight Team to lead QA professionals ensuring LTSS eligibility and service authorization compliance. You will coordinate with Area Agencies on Aging and other partners, guiding daily operations and policy development while maintaining cross‑department collaboration.

The role requires Michigan residency, RN or LBSW licensure, and 3+ years in complex populations with 2+ years in management.

Qualifications

• Must reside in Michigan.
• Active, unrestricted licensed RN or LBSW in Michigan.
• 3+ years of experience with complex populations, home and community-based services or managed care.
• 2+ years of management or supervisory experience.
• Proficiency with Microsoft Office applications, including Excel and PowerPoint.
• Proficiency in analyzing and interpreting data trends.
• Excellent oral and written communication and interpersonal skills.
• Care Management certification (CCM) preferred.
• 3+ years of managed care experience (Medicare/Medicaid) preferred.
• Bilingual or multilingual abilities (English/Spanish, Arabic, etc.) preferred.

Responsibilities

• Oversee the External Oversight Team and monitor compliance to HCBS eligibility and service authorization metrics.
• Plan and oversee daily operations of the team and allocate resources for projects.
• Collaborate with internal Humana departments and external stakeholders.
• Develop policies and procedures to ensure state and federal compliance and share best practices.
• Provide real-time training to downstream entities on ongoing compliance requirements.

Skills

RN license

LBSW/LMSW/LMSW license

Data analysis

Excel

PowerPoint

Communication

Education

RN license

LBSW/LMSW/LMSW license

Tools

Microsoft Office

Job description

Become a part of our caring community

Humana is seeking a Manager, Quality Assurance (External LTSS Oversight Team Manager) who will lead a team of Quality Assurance Professionals responsible for ensuring consistency of use and compliance to state and Humana requirements for Long-Term Services and Supports (LTSS) eligibility determination and service authorization. You will collaborate with external partners such as Area Agencies on Aging (AAA) and assist with monitoring day-to-day operational activities with AAAs and other external LTSS partners. You will work within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receive assignments in the form of objectives and determine approach, resources, schedules, and goals.

Oversee the External Oversight Team (Quality Assurance professionals and Care Management Support Assistants) staff and monitors compliance to HCBS eligibility determination, service authorization, and other key LTSS compliance or operational metrics as identified. Responsible for planning and overseeing daily operations of team. This includes making decisions related to resources and approach for projects and initiatives involving own departmental area and requires cross departmental collaboration. Conduct briefings, area meetings, and maintains frequent contact with internal and external stakeholders such as other Humana departments.

Liaise and maintain frequent contact with external stakeholders and vendors such as Area Agencies on Aging, conducts briefings and area meetings, Develop policies and procedures to ensure compliance with state and federal requirements and incorporate industry best practices. Provide real-time training/re‑training to downstream entities on ongoing compliance requirements, policies, and procedures. Support leadership in meeting goals of the department/market. May participate in Interdisciplinary team meetings.

Use your skills to make an impact

Required Qualifications

• Must reside in Michigan.
• An active, unrestricted licensed Registered Nurse (RN) or Licensed Social Worker (LBSW, LLMSW, LMSW) in the state of Michigan.
• Three (3) or more years of professional experience working with complex populations, home and community-based services or in managed care settings.
• Two (2) or more years of management or supervisory experience.
• Comprehensive knowledge of Microsoft Office applications, including Excel, and PowerPoint.
• Proficiency in analyzing and interpreting data trends.
• Exceptional oral and written communication and interpersonal skills with the ability to quickly build rapport.

Preferred Qualifications

• Care Management certification (CCM).
• Three (3) or more years of managed care experience in Medicare and/or Medicaid, specifically in the delivery of care for elderly or special needs populations such as the Aged, Blind and Disabled (ABD) and those enrolled in Long-Term Services and Supports (LTSS) Waiver Services, in hospice and/or in nursing facilities.
• Proficiency in analyzing and interpreting financial trends.
• Previous experience in utilization management, discharge planning and/or home health or rehabilitation.
• Experience with initiating service plans for members.
• Experience with disease management, health promotion, coaching and wellness.
• Health Plan experience.
• Bilingual or Multilingual: English/Spanish, Arabic, Chaldean Neo-Aramaic, or other - Must be able to speak, read and write in both languages without limitations and assistance (see Additional Information for more information on language proficiency assessments).

Additional Information

• Workstyle: This is a remote position that requires some travel.
• Travel: Up to 25% travel to Humana's Detroit office for in-person team engagement and collaboration meetings.
• Typical Workdays and Hours: Monday - Friday; 8:00am - 5:00pm Eastern Time (ET).
• Direct Reports: Up to 15.
• Language Proficiency Assessment: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.
• 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. 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