Quality Assurance Professional

Humana Inc; Michigan; Hybrid; USD 65,000 - 89,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) plan

Paid time off

Disability insurance

Life insurance

Job summary

Humana Inc. is seeking a Quality Assurance Professional 2 to review LTSS contractor documentation and performance to ensure compliance with contract scope and state and federal regulations.

You will ensure adherence to policies, procedures, and regulations, help prevent fraud, waste, and abuse, and interpret strategy with minimal direction while reporting to LTSS leadership. This is a remote position with occasional travel to Humana's Detroit, Michigan location; typical schedule is Mon–Fri, 8

Qualifications

• Bachelor's degree in a related field.
• 2+ years in care management/utilization management/QA or population health for LTSS.
• Experience with Managed Care Organizations.
• Analytical skills to identify trends and ensure guideline adherence.
• Proficient in Word, Excel, PowerPoint, and Outlook.

Responsibilities

• Review LTSS documentation and performance for compliance with contract scope and regulations.
• Conduct audits to prevent fraud, waste, and abuse; summarize deficiencies and risks.
• Interpret guidance and determine appropriate actions in varied situations.
• Collect and analyze data to assess outcomes and metrics for the team.
• Ensure adherence to MDHHS, NCQA, CMS, and Humana policies.

Skills

Data analysis

Care management

Utilization management

QA and compliance

Microsoft Office

Education

Bachelor's degree

Licensed professional credential (preferred)

Tools

Microsoft Office

Job description

Become a part of our caring community

The Quality Assurance Professional 2 reviews Long-Term Services and Support (LTSS) contractor documentation and performance to ensure compliance with contract scope of work, and state and federal regulations.

You will ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse to ensure appropriate course of action.

You will understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

Your work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Comply, conduct, and summarize 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 as Home- and Community-Based Services (HCBS) service calculators and nursing facility level of care determination assessments to ensure accurate and consistent application of state and Humana guidelines.

Ensure Michigan Department of Health and Human Services (MDHHS), National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and Humana Gold-Plus Integrated 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 require minimal direction and receives guidance where needed.

Other duties as assigned by the LTSS leadership team. Use your skills to make an impact

Required Qualifications

• Must reside in Michigan or within a 40-mile radius of the Michigan border in Ohio or Indiana.
• Bachelor's degree.
• Two (2) or more years of experience in care management, utilization management, quality assurance and/or population health supporting the Long-Term Services and Supports (LTSS) population.
• Previous experience working with Managed Care Organization.
• Proficiency in analyzing, tracking, and interpreting data trends to identify improvement opportunities and ensure adherence to operational guidelines, policies, and procedures.
• Proficient with Microsoft Office products including Word Excel, Power Point, and Outlook.

Preferred Qualifications

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

Additional Information

Workstyle: This is a remote position.

Travel: Up to 10% travel, including occasional travel for audits, accreditation-related activities, and team engagement meetings at Humana's Detroit, Michigan location.

Typical Work Schedule: Monday through Friday; 8:00 AM to 5:00 PM Eastern Time (ET).

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 be required.

Scheduled Weekly Hours 40 Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $65,000 - $88,600 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

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.

• 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
• many other opportunities

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 to deliver 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 atHumana.comand atCenterWell.com.

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.