Quality Compliance Nurse (Maternal-Child Health/EPSDT)

Humana; Virginia (MN); Remote; USD 71,000 - 98,000; Full time

Job summary

A leading health insurance company seeks a Quality Compliance Nurse specializing in Maternal-Child Health. In this role, you will support Medicaid enrollees under the EPSDT program, ensuring access to preventive and high-quality healthcare services. Your expertise in maternal and child health will contribute to important health initiatives, as you collaborate with various stakeholders to promote wellness in your community.

Benefits

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Short-term and long-term disability

Life insurance

Qualifications

• Two or more years' experience in Maternal Child Health or EPSDT.
• Experience in Medicaid programs or managed care case management.

Responsibilities

• Conducts telephonic outreach to encourage enrollees to access preventative care.
• Reviews EPSDT services and assessments and HEDIS data for quality improvement.
• Coordinates with community partners to support delivery of MCH and EPSDT services.

Skills

Excellent communication skills

Intermediate proficiency in Microsoft Programs

Education

Active Licensed Practical Nurse (LPN) or Registered Nurse (RN) license in Virginia

Job description

Quality Compliance Nurse (Maternal-Child Health/EPSDT)

Join to apply for the Quality Compliance Nurse (Maternal-Child Health/EPSDT) role at Humana

Quality Compliance Nurse (Maternal-Child Health/EPSDT)

Join to apply for the Quality Compliance Nurse (Maternal-Child Health/EPSDT) role at Humana

This range is provided by Humana. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$71,100.00/yr - $97,800.00/yr

Become a part of our caring community and help us put health first

Humana Healthy Horizons in Virginia is looking for a Quality Compliance Nurse Professional 2 (Maternal-Child Health/EPSDT) who will collaborate with all departments to ensure timely access of the delivery of high-quality maternal and postpartum care and Early Periodic Screening, Diagnosis, and Treatment(EPSDT) services for individuals under the age of twenty-one years, including the promotion of family planning services and preventive health strategies. The Quality Compliance Nurse Professional 2 (Maternal-Child Health/EPSDT) works to ensure that children enrolled in Humana Healthy Horizon in Virginia Medicaid under the EPSDT program receive necessary preventative care, screenings, and treatments. They work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

• Conducts telephonic outreach to encourage enrollees to access preventative care and assist with appointment and transportation scheduling as necessary.
• Reviews EPSDT services and assessments and HEDIS data to identify gaps in care and targeted interventions to increase utilization of well-child visits, exams, screenings and services.
• Conducts medical record and/or claims reviews of providers working with children under the age of twenty-one to ensure experience in addition treatment in children and adolescents.
• Identifies and coordinates services for identified member needs, specific to Maternal-Child Health (MCH) and Periodic Screening, Diagnosis, and Treatment (EPSDT).
• Coordinates with community partners to support the delivery of MCH and EPSDT services, including development and implementation of population health programs and community events.
• Conducts reviews of coverage for all members under the age of twenty-one to ensure appropriateness of benefits as described under the medically necessary treatment for EPSDT benefit.
• Collaborates with Provider Relations personnel to support Provider education efforts related to MCH and EPSDT.
• Ensures compliance with state and federal requirements and NCQA standards that pertain to MCH and EPSDT.
• Participates as needed in quality committees and quality improvement related meetings with internal and external partners to advise on MCH and EPSDT performance and related quality initiatives.
  
  

Required Qualifications

Use your skills to make an impact

• Must reside in the Commonwealth of Virginia.
• An active, unrestricted licensed Practical Nurse (LPN) or a licensed Registered Nurse (RN) with an active, unrestricted license in the Commonwealth of Virginia.
• Two (2) or more years' experience working in Maternal Child Health (MCH) or Early Periodic Screening diagnosis and Treatment (EPSDT).
• Two (2) or more years' professional experience in Medicaid programs, managed care case management, quality improvement in healthcare or pediatric office operations.
• Intermediate proficiency in Microsoft Programs specifically, Word, Excel and PowerPoint.
• Excellent communication skills, both oral and written.
• Ability to work independently under general instructions, self-directed and motivated.
  
  

Preferred Qualifications

• Prior experience working with healthcare quality metrics in a fast past insurance or health care setting.
• Previous experience working with Clinical Auditing or Clinical Review.
• Prior experience working with healthcare providers.
• Knowledge of HEDIS/Stars/CMS/Quality.
• Detail orientated and comfortable working with tight deadlines in a fast-paced environment.
• Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations and assistance. See “Additional Information” section for more information.
  
  

Additional Information

• Workstyle: This is a remote position with minimal travel.
• Travel: Up to 10% to attend onsite team engagement meetings in Humana Healthy Horizons, Glen Allen, VA office location and community events throughout Virginia.
• Typical Workdays/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.
  
  

Work from Home Internet Statement

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 recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Humana will provide Home or Hybrid Home/Office employees 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.
  
  

Interview Format

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

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.

$71,100 - $97,800 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

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.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Insurance

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