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The Quality Audit Professional 2 supports the Healthcare Quality Management Team in administering and implementing the Clinical Quality Management Program (CQMP) in support of TRICARE’s commitment to quality healthcare for beneficiaries.

Humana Government Business government contract requires U.S. citizenship for this position.

The Clinical Quality Registered Nurse (RN) collects and reviews records, summarizes issues, works with Medical Director as needed, and implements corrective actions as assigned. Coordinates case presentations and presents to Patient Safety Peer Review Committee. Audits quality cases for compliance and participates in department projects as available. 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, requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Key Accountabilities :

• 30% Reviews medical records, creates case summaries, and presents potential quality issue (PQI) cases to Medical Director for review.

• 20% Review PQI’s from all sources to determine the need for medical record review.

• 15% Provides assistance to Medical Directors to ensure corrective action plans (CAPs) are developed & implemented as identified through quality management reporting. Monitors CAP for timeliness and enters data into the Provider Trending Database according to Policy and Procedure.

• 15% Monitors cases entered in the Clinical Quality Management Database (CQMD) for accuracy, timeliness of completion, and documentation.

• 10% Participates in case presentation and discussion at Patient Safety Peer Review Committee (PSPRC) meetings.

• 10% Participates in departmental projects such as focused reviews as available.

Use your skills to make an impact

Required Qualifications

• Our Department of Defense contract requires U.S. Citizenship for this role

• Successfully receive approval for government security clearance (Via National Background Investigation Services NBIS)

• 3 or more years of clinical nursing experience

• Active R.N. (Registered Nurse) license in state of employment

• 2 or more years of Utilization Review (UR), Case Management (CM) or Quality Management (QM) experience

• Provide coverage in the Eastern Time Zone hours

• Ability to work independently under general instructions, self-directed and motivated

• Strong analytical skills, able to manipulate and interpret data

• Comprehensive knowledge of Microsoft Office Word, Excel and PowerPoint

Preferred Qualifications

• Accreditation (URAC, NCQA or JCAHO) experience

• Clinical nursing experience in a hospital or physician office practice

• Knowledge of HEDIS/Stars/CMS/Quality

Additional Information

*PLEASE MAKE SURE YOU ATTACH YOUR RESUME TO YOUR APPLICATION (PDF OR WORD FORMAT) * * *

Interview Process

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.

• Text Prescreen : Shortly after submitting your application, you may receive both a text message and email requesting you to complete 10 to 15 prescreen questions with either yes or no answers. The text message may arrive prior to the email. If you prefer to answer via computer or tablet, wait for the email.

• Video Prescreen : If you are successful with your text screen, you will receive another communication to record a Video Prescreen. This is an online video activity using your phone, tablet, or computer; however, most candidates prefer using a computer or tablet.

• Interviews : Some candidates will be invited to interview. If so, the recruiter will reach out to schedule.

• Offers : Finalists from the interview will be contacted by a recruiter to discuss an offer for the job

• Note : Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed.

Nationwide Remote - This is a remote nationwide position.

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.

$63,400 - $87,400 per year

This 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 veteran status. 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=Humana_Website.