QA External LTSS Oversight Professional

Humana; Myrtle Point (OR); Remote; USD 65,000 - 89,000; Full time

Job summary

A leading healthcare organization is seeking a Quality Assurance Professional to ensure compliance in LTSS operations. This remote role requires strong analytical skills and prior experience in healthcare compliance. Candidates should possess a relevant Bachelor’s degree and have excellent communication abilities. A competitive salary and comprehensive benefits package are offered.

Benefits

Competitive benefits including medical, dental, and vision

401(k) retirement savings

Paid time off and holidays

Qualifications

• Minimum of 2 years’ experience in LTSS.
• Previous experience with Managed Care Organization.
• Licensed healthcare professional in Michigan is preferred.

Responsibilities

• Conducts compliance audits/reports.
• Collect, review records, and analyze data.
• Ensure auditing is completed timely.

Skills

Proficient with Microsoft Office products

Exceptional oral and written communication

Ability to work independently

Education

Bachelor’s degree in social work or nursing (unlicensed)

Job description

Overview

Become a part of our caring community and help us put health first. The Quality Assurance Professional reviews LTSS contractor documentation and performance to ensure compliance with contract scope of work, and state and federal regulations. The Quality Assurance Professional ensures adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse to ensure appropriate course of action. The Quality Assurance Professional understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Quality Assurance Professional work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

• Complies, conducts, and summarizes compliance audits/reports to include deficiencies and risks.
• Collect, review records, summarize issues and analyze data daily, weekly, monthly, or as needed to assess outcome and operational metrics for the team and individuals.
• Conduct inter-rater reliability audits for multiple vendor activities such HCBS service calculators and nursing facility level of care determination assessments to ensure accurate and consistent application of state and Humana guidelines.
• Proficiency in analyzing, tracking, and interpreting data trends, operational guidelines and procedures are adhered to.
• Ensure MDHHS, NCQA, CMS, and Humana's Healthy Horizon's Policy and Procedures are followed.
• Ensure auditing is completed timely and communicated with leadership.
• Make decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Other duties as assigned per CLTSS leadership team.

Required Qualifications

• Must reside in the state of Michigan or within 40 miles of the border in Indiana or Ohio.
• Bachelor’s degree in social work or nursing (unlicensed)
• A minimum of 2 years’ experience in LTSS.
• Proficient with Microsoft Office products including Word, Excel, Power Point, and Outlook.
• Previous experience with Managed Care Organization.
• Ability to work independently under general instructions and with a team.
• Exceptional oral and written communication and interpersonal skills.
• This is mainly a virtual position; occasional travel for meetings or audits may be required to ensure accreditation is met.

Preferred Qualifications

• Licensed healthcare professional in the state of Michigan: LPN, RN, LSW, LISW.
• Previous Medicare/Medicaid, MDHHS, CMS, and NCQA experience.

Additional Information

• Workstyle: This is a remote position.
• Travel: This is a mainly virtual position, however, it may require occasional travel for meetings or audits to ensure accreditation is met and as such the ability to travel as needed is necessary.
• Workdays and Hours: Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST).
• Language Assessment Statement: 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.
• Scheduled Weekly Hours: 40
• Pay Range: $65,000 - $88,600 per year. This job is eligible for a bonus incentive plan. The incentive opportunity is based upon company and/or individual performance.
• Description of Benefits: Humana offers competitive benefits including medical, dental and vision, 401(k) retirement savings, paid time off, holidays, volunteer time off, parental and caregiver leave, disability coverage, life insurance, and more.

About us

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.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.