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The Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Please Note: This role will follow a four-day, 10-hour shift schedule within a Wednesday through Sunday work week. The assigned schedule will be either Wednesday through Saturday or Thursday through Sunday, with work hours scheduled between 8:00 a.m. and 8:00 p.m. Eastern Time.
The Compliance Nurse 2 collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related workstreams. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Assignments are varied and often complex, requiring independent judgment, critical thinking, and interpretation of guidelines to determine appropriate courses of action. Follows established guidelines, regulatory turnaround times, and procedures for processing QIO fast track appeals and expedited authorization requests.
Use your skills to make an impact
Required Qualifications
Licensed Registered Nurse (RN) in a compact state with no disciplinary action.
Must have valid compact license or reside in a compact state and be eligible to upgrade to compact licensure.
Three (3) or more years of consecutive UM experience for a health plan OR two (2) or more years of consecutive UM auditing experience in a traditional Quality or Compliance role at a health plan OR one (1) or more years of home health utilization management experience for a health plan
Effective telephonic and virtual communication skills
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Ability to work independently under general instructions and within a team.
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
The ideal candidate for this opening would be a current member of the One Home / Home Solutions UM Team who has been in their current position for 12+ months
Bachelor’s degree in nursing or related field
Clinical experience in a home health and/or Skilled Nursing Facility setting
Clinical experience working QIO appeals, expedited request reviews and/or compliance
Health Plan experience
Additional Information
This position is within a department that operates in EST.
This position offers a flexible schedule of Monday to Sunday, between 8 am and 8 pm EST with occasional overtime.
This position follows a 4-day workweek consisting of ten-hour shifts, available schedules include:
Wednesday – Saturday
Thursday – Sunday
Work-At-Home Requirements
Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role).
A minimum standard speed for optimal performance is 25mbs download x 10mbs upload is required.
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.