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Humana Inc. is seeking a Quality Audit Professional to analyze quality issues and support the Clinical Quality Management Program. The role requires an active RN license and extensive clinical experience to ensure quality healthcare delivery. This is a remote position with competitive compensation and benefits.
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The Quality Audit Professional 2 supports the Healthcare Quality Management Team in administering and implementing the Clinical Quality Management Program (CQMP) in support commitment to quality healthcare for beneficiaries. The Quality Audit Professional 2 collects and reviews records, summarizes issues, works with Medical Director as needed, and implements corrective actions as assigned. Coordinates case presentations and presents to Patient Safety Peer Review Committee. Audits quality cases for compliance and participates in department projects as available. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Key Accountabilities -
Reviews medical records, creates case summaries, and presents potential quality issue (PQI) cases to Medical Director for review
Provides assistance to Medical Directors to ensure corrective action plans (CAPs) are developed & implemented as identified through quality management reporting. Monitors CAP for timeliness, and enters data into the Provider Trending Database according to Policy and Procedure
Monitors cases entered in the Clinical Quality Management Database (CQMD) for accuracy, timeliness of completion, and documentation
Participates in case presentation and discussion at Patient Safety Peer Review Committee (PSPRC) meetings
Review PQI's from all sources to determine the need for medical record review
Participates in departmental projects such as focused reviews as available
Required Qualifications
Our Department of Defense Contract requires U.S. citizenship for this position
Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services)
HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico.
Active licensed RN in state of employment
3 years clinical RN experience
2 years of UR, CM, or QM experience
Strong analytical skills, experience manipulating and interpreting data
Ability to work 7 - 4 p.m. E.T. or 8 - 5 p.m. E.T.
Preferred Qualifications
Accreditation (URAC, NCQA or JCAHO) experience
QM experience
Work at Home Requirements
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
Satellite, cellular and microwave connection can be used only if approved by leadership
Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Scheduled Weekly Hours
40Pay 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.$71,100 - $97,800 per yearThis 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
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.