Quality Assurance Professional

Humana; United States; À distance; USD 65 000 - 89 000; Plein temps

Avantages offerts par ce poste

Remote work

Travel up to 10%

Résumé du poste

Humana is seeking a Quality Assurance Professional to review LTSS contractor documentation and performance for compliance with contract scope and state/federal regulations. You will prevent fraud, waste, and abuse, interpret guidelines, and coordinate with LTSS leadership to ensure timely audits.

The role requires Michigan proximity or travel, a Bachelor’s degree, 2+ years in care/utilization management, and strong data analysis.

Qualifications

• Proficiency in analyzing, tracking, and interpreting data trends to identify improvement opportunities and ensure adherence to operational guidelines, policies, and procedures.
• Two (2) or more years of experience in care management, utilization management, quality assurance and/or population health supporting LTSS.
• Previous experience working with Managed Care Organization.

Responsabilités

• 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 HCBS service calculators and nursing facility level of care determination assessments to ensure accurate and consistent application of state and Humana guidelines.
• Ensure MDHHS, NCQA, CMS, and Humana policies 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.

Connaissances

Data analysis

Care management

Utilization management

Formation

Bachelor's degree

Outils

Microsoft Office

Description du poste

Become a part of our caring community

The Quality Assurance Professional 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

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 Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare serv