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Humana - Little Rock, AR
posted 2 months ago
About the position
The RN Compliance Nurse 2, Quality Assurance Auditor at Humana is responsible for reviewing utilization management activities and documentation to ensure compliance with policies, procedures, and regulations. This role focuses on preventing and detecting fraud, waste, and abuse while ensuring mandatory reporting is completed. The auditor conducts compliance audits, collects and analyzes data, and provides detailed audit results to support clinical operational teams in identifying corrective actions.
Responsibilities
- Review utilization management activities and documentation for compliance with policies and regulations.
- Conduct and summarize compliance audits.
- Collect and analyze data to assess operational metrics for the team and individuals.
- Perform pre-service denial and quality assurance audits and summarize findings for corrective action plans.
- Revise and edit member pre-service denial letters to ensure compliance with Medicare requirements.
- Analyze authorizations and medical records according to departmental policies and regulatory requirements.
- Provide detailed audit results highlighting documentation issues, decision-making errors, and non-compliance.
- Manage internal and external communications to verify data related to audit functions.
- Recommend process changes or training opportunities based on audit trends.
- Coordinate special compliance projects and additional tasks as assigned by leadership.
Requirements
- Current Unrestricted Florida RN license or Compact RN License in the state of residence.
- Experience with Utilization Management and Quality assurance audits.
- Clinical experience in an Acute Care setting.
- Proficiency in Microsoft Office Products (Word, Excel, PowerPoint).
Nice-to-haves
- BSN or Bachelor's degree in a related field.
- Bilingual (English, Spanish).
- Experience as a utilization management Auditor.
- Health Plan experience with large carriers.
- Experience working with MCG/Interqual guidelines.
- Proficiency in Microsoft Outlook.
- Excellent computer skills and ability to navigate multiple applications.
- Experience in a Skilled and/or Rehabilitation Clinical setting.
