Remote Quality Assurance Auditor — LTSS Compliance

Humana; United States; Remote; USD 65,000 - 89,000; Full time

Benefits offered by this job

Remote work

Travel up to 10%

Job summary

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.

Responsibilities

• 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.

Skills

Data analysis

Care management

Utilization management

Education

Bachelor's degree

Tools

Microsoft Office

Job description

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.