Become a part of our caring community and help us put health firstThe Compliance Utilization Management 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. The role analyzes report data daily, weekly, monthly, and as needed to assess and identify trends that pose a compliance risk to UM authorization determinations.Schedule: Two weekend shifts available10-hour shift Thursday, Friday, Saturday, and Sunday until 6:30 PM Eastern Time10-hour shift Saturday, Sunday, Monday, and Tuesday until 6:30 PM Eastern TimeAbility to work holidays on a rotating schedule. (about 2 holidays per year)The Compliance Utilization Management Nurse 2 ensures mandatory reporting completed. Conducts and summarizes compliance audits.
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 areas
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
Reviews denial letters issued to members and providers to ensure compliance with accreditation entities and State contractual requirements. Follows established guidelines/procedures
Use your skills to make an impactRequired Qualifications
Active unrestricted Licensed Registered Nurse, (RN), in your state of residence without disciplinary action and ability to obtain multiple licenses
A minimum of three years varied clinical nursing experience
Experience in utilization management
Ability to work independently under general instructions and with a team
Intermediate or better proficiency using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment
Preferred Qualifications
BSN
2 years of experience in utilization management using MCG guidelines
Behavioral Health Utilization Management, working knowledge of ASAM criteria
Health Plan experience working with large carriers
Previous Medicare/Medicaid experience a plus
Certification in Case Management a plus (CCM)
Experience with National Committee for Quality Assurance (NCQA) requirements
Workstyle: Remote work at HomeLocation: Compact State PreferredSchedule: Two weekend shifts available
10-hour shift Thursday, Friday, Saturday, and Sunday until 6:30 PM Eastern Time
10-hour shift Saturday, Sunday, Monday, and Tuesday until 6:30 PM Eastern Time
Ability to work holidays on a rotating schedule. (about 2 holidays per year)
Travel: 1 to 2 time annually to the local market office as needed for meetingsWork at Home Guidance To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates 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
Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense
Humana will provide Home or Hybrid Home/Office associates 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 FormatAs part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Modern Hire Voice 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.If you are selected for a first-round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate in a Modern Hire Voice interview. In this interview, you will listen to a set of interview questions over your phone, and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/Buzz and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.SSN AlertHumana 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 [email protected] with instructions on how to add the information into your official application on Humana's secure website.BenefitsHumana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security-both today and in the future, including:Health benefits effective day 1; Paid time off, holidays, volunteer time and jury duty pay; Recognition pay; 401(k) retirement savings plan with employer match; Tuition assistance; Scholarships for eligible dependents; Parental and caregiver leave; Employee charity matching program; Network Resource Groups (NRGs); Career development opportunities#L1-RemoteScheduled Weekly Hours40Pay RangeThe 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.$69,800 - $96,200 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, 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 usHumana 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 EmployerIt 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 because he or she is a protected veteran. It is also the policy of Humana to 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.Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=HumanaWebsite.