Senior Compliance Nurse
Senior Compliance Nurse
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$ 78400 - 107800
1 Vacancy
Job Description
Become a part of our caring community and help us put health first
The Senior Compliance Nurse reviews utilization management activities and documentation to ensure adherence to policies procedures and regulations and to prevent and detect fraud waste and abuse. The Senior Compliance Nurse work assignments involve moderately complex to complex issues where the analysis of situations or data requires an indepth evaluation of variable factors.The Senior Compliance Nurse is responsible for maintaining updating and submitting clinical coverage policies for the Kentucky Medicaid market. Additionally this role is responsible for completing audits of records to ensure compliance with process and expectations. This role also helps to support compliance and contractual auditing and data requests from Kentucky Department for Medicaid services.
Use your skills to make an impact
Required Qualifications
- Unrestricted Registered Nurse license in the state of Kentucky or have a compact license
- Bachelors degree or 5 years or more relevant experience in lieu of degree
- 5 years of technical experience with the ability to navigate multiple screens and databases with proficiency with Microsoft Office (Excel Word Power Point Visio) and other virtual platforms i.e. zoom and Teams
- 2 years Medicare/Medicaid or Health Plan Experience in Utilization Management
- Great Communication Skills Written and Verbal
- 2 years exp with compliance auditing with knowledge of NCQA UM Requirements
- Experience with reviewing data to identify trends process gaps and/or Associate learning opportunities
- Experience with leading process change initiatives
- Experience utilizing MCG
- Must be available to attend meetings in the Market Office the expectation is to reside in KY or a county that borders the state of KY and willingness to report to the office for occasional meetings
Preferred Qualifications
- MCG Certification
- Experience with creating data presentations in the form or graphs/charts/graphics
- Presentation skills on reporting
- Proficient working with CGX QuickBase
- Project Management Experience
- Bilingual in any language you are fluent in reading and writing in addition to the English language
Additional Information
- Schedule: Monday to Friday from 8 am to 5 pm Eastern Standard Time Zone (regardless of where you reside)
- Work Location: KY or a county that borders the state of KY and willingness to report to the office for occasional meetings
Work At Home Requirements
To ensure Home or Hybrid Home/Office employees ability to work effectively the selfprovided 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 required; wireless wired cable or DSL connection is suggested.
- Satellite cellular and microwave connection can be used only if approved by leadership.
- Employees who live and work from Home in the state of California Illinois Montana or South Dakota will be provided a biweekly payment for their internet expense.
- 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 decisionmaking 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.
SSN Alert Statement: Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number if it is not already on file. When required an email will be sent from with instructions on how to add the information into your official application on Humanas secure website.
Scheduled Weekly Hours
40Pay 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.Description of Benefits
Humana Inc. and its affiliated subsidiaries (collectively Humana) offers competitive benefits that support wholeperson wellbeing. 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) shortterm and longterm 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 veteran status. It is also the policy ofHumanato take affirmative action to employ and to advance in employment all persons regardless of race color religion sex sexual orientation gender identity national origin age marital status genetic information 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.
Required Experience:
Senior IC
Employment Type
Full-Time
