Senior Quality Assurance, Professional

Humana; Michigan; Remote; USD 86,000 - 119,000; Full time

Job summary

A leading health insurance organization is seeking a Senior Quality Assurance Clinical Professional to ensure compliance and quality in clinical services. The role requires a valid Nurse license and a Bachelor's degree, along with experience in medical records and Medicare. Daily responsibilities include conducting audits, supporting quality improvement initiatives, and collaborating on compliance projects. This position is remote but occasional travel to the office may be required.

Benefits

Competitive medical, dental, and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Short-term and long-term disability

Life insurance

Qualifications

• Active Nurse license required.
• Must reside in Michigan.
• Minimum of 6 months experience with medical records.
• Experience with Medicare Prior Authorization is essential.
• Strong attention to detail is crucial.

Responsibilities

• Conduct case audits with Clinical Operations Medical Directors.
• Assist in audit preparation and visits.
• Support quality improvement and compliance projects.
• Engage in governance meetings.

Skills

Excellent interpersonal skills

Written communication skills

Verbal communication skills

Attention to detail

Ability to build positive relationships

Independent operation

Strategic thinking

Proficient in Microsoft Office

Education

Bachelor's degree

Bachelor of Science in Nursing (BSN)

Tools

Microsoft Access

Database tools

Job description

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

The Senior Quality Assurance, Clinical Professional consults and collaborates with clinicians to ensure high accountability of compliance and quality. The Senior Quality Assurance, Clinical Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Senior Quality Assurance, Clinical Professional supports and implements programs to establish high quality standards in clinical products and services. Support, develop and operationalize methods to drive program and service consistency. Provide and support training and process management as needed. Requires applicable State licensure in field of study: Registered Nurse (RN), Licensed Masters Clinical Social Worker (LCSW), Licensed Masters Social Worker (LMSW-ACP), Licensed Professional Counselor (LPC) or other applicable professional license. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Use your skills to make an impact

Essential Functions of the Job and Percentage of Time Allotted

• Conduct both concurrent and retrospective case audits worked by Clinical Operations Medical Directors – 70%
• Assist with audit prep and audit visits – 10%
• Assist with quality improvement and compliance projects – 10%
• Assist with products involving Policy, Process and Learning – 5%
• Participate in Governance Meetings – 5%

Required Qualifications

• Nurse with active license
• Must live in the state of Michigan
• Bachelor's degree
• Minimum of 6 months experience in all of the following:
  • Reading and interpreting medical records
  • Reviewing medical literature/publications
  • Working with Medicare Prior Authorization; clinical criteria (NCDs, LCDs, MCG or similar guidance)
• Excellent interpersonal, written, and verbal communications skills with high attention to detail and accuracy
• Experience building positive cross-functional relationships and communicating issues in a constructive manner
• Demonstrated ability to operate independently and apply strategic thinking to task-oriented work
• Proficient in Microsoft Office products; must be able to utilize Microsoft Access or demonstrate ability to utilize other database tools

Preferred Qualifications

• Bachelor of Science in Nursing (BSN)
• Researching Medicare and Medicaid regulatory requirements
• Working in an audit-based or compliance oversight role, including documentation of findings according to a defined methodology; 2+ years preferred
• Interpreting and utilizing regulations governing the health care industry (CMS and/or NCQA)
• Familiarity with Humana’s Clinical Guidance Exchange (CGX)
• Providing continuous quality improvement
• Six Sigma Lean or Green Belt certified

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.$86,300 - $118,700 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.

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.