Senior Quality Compliance Professional (Virginia Medicaid)

Humana Inc; Virginia (MN); Remote; USD 78,000 - 108,000; Full time

Job summary

A leading company in healthcare is looking for a Senior Quality Compliance Professional. This role will focus on overseeing quality reviews and implementing quality control processes, ensuring compliance with healthcare standards. Ideal candidates will have at least three years of experience in medical audits, strong analytical and leadership skills, along with an active nursing license in Virginia. This remote position includes up to 25% travel for onsite quality audits and team engagement.

Benefits

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Short-term and long-term disability insurance

Life insurance

Flexible working hours

Qualifications

• Three years of professional experience in medical audits and clinical reviews.
• Experience working with healthcare providers and quality in a fast-paced setting.
• Bilingual or multilingual capabilities preferred.

Responsibilities

• Conducts and manages medical records reviews to ensure proper documentation.
• Develops and implements quality assurance initiatives to improve patient outcomes.
• Prepares reports for senior management and evaluates compliance with standards.

Skills

Analytical skills

Leadership

Communication

Relationship building

Data analysis

Education

Active, unrestricted licensed Practical Nurse (LPN) or Registered Nurse (RN) in Virginia

BSN or bachelor's degree in health administration or related field

Tools

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Job description

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

Humana Healthy Horizons in Virginia is seeking a Senior Quality Compliance Professional who will be is a key leader focusing on ensuring quality and safety of patient care and will provide oversight of quality reviews and research to support quality assurance and implementation of quality control process. The Senior Quality Compliance Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. They exercise considerable latitude in determining objectives and approaches to assignment and influences the department’s strategy.

The Senior Quality Compliance Professional will conduct and manage medical records reviews to ensure proper documentation, coding and coordination of care and service for our members and accurate reporting of outcomes.

• Collects and analyzes data to develop process improvement strategies and/or corrective actions as needed.
• Reviews medical records for supplemental data and enter data in supplemental data base.
• Conducts medical record audits and assessments to evaluate compliance with established standards and to ensure compliance with National Committee for Quality Assurance (NCQA), Centers of Medicare & Medicaid Services (CMS) and Department of Medical Assistance Services (DMAS) standards.
• Prepares for external audits and addresses any findings or corrective actions.
• Develops and implements quality assurance initiatives aimed at improving patient care and outcomes and monitors the effectiveness of these programs and make necessary adjustments.
• Tracks and monitors compliance with Critical Incident (CI) and Quality Management Reviews (QMR) reporting requirements and documentation.
• Analyzes clinical data and quality metrics to identify trends, areas for improvement, and compliance issues.
• Prepares reports for senior management and other functional areas.
• Assists in the development and revision of organizational policies and procedures related to quality and compliance.
• Works closely with clinical and administrative staff to promote best practices in quality care and ensure alignment with compliance goals.
• Provides leadership through coaching and mentoring of a small team of quality reviewers and audits, setting and tracking both team and individual goals.

Use your skills to make an impact

Required Qualifications

• 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.
• Three (3) years of professional experience in medical audits and clinical reviews.
• Two (2) or more years of experience working with quality in a fast-paced insurance or health care setting.
• Previous leadership experience in a clinical or nonclinical setting.
• Experience working with healthcare providers.
• Comprehensive knowledge of Microsoft Word, Excel and PowerPoint.
• Excellent communication skills, both oral and written.
• Strong relationship building skills.
• Ability to travel to region-based providers and members for face-to-face interviews, quality onsite audits and medical reviews.
• This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance.Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

Preferred Qualifications

• BSN or bachelor’s degree in health administration or a related field.
• One (1) or more years of experience working directly with Healthcare Effectiveness Data and Information Set (HEDIS) measures and quality improvement initiatives measures.
• Three (3) years of managed care health plan experience.
• Knowledge of Humana's internal policies, procedures and systems.
• 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 travel.
• Travel: Up to 25% to region-based providers and members for face-to-face interviews, quality onsite audits and medical reviews. You may be required to attend onsite team engagement meetings in Humana Healthy Horizons, Glen Allen, VA office location.
• Typical Workdays/Hours: Monday – Friday; 8:00am -5:00pm, Eastern Standard Time (EST).
• Direct Reports: Up to 3 associates.
• 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.$78,400 - $107,800 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.

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.