Quality Audit Professional

Become a part of our caring community and help us put health first The Quality Audit Professional 2 analyzes and investigates quality issues. The Quality Audit Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Quality Audit Professional 2 supports the Healthcare Quality Management Team in administering and implementing the Clinical Quality Management Program (CQMP) in support commitment to quality healthcare for beneficiaries. The Quality Audit Professional 2 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 Reviews medical records, creates case summaries, and presents potential quality issue (PQI) cases to Medical Director for review 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 Monitors cases entered in the Clinical Quality Management Database (CQMD) for accuracy, timeliness of completion, and documentation Participates in case presentation and discussion at Patient Safety Peer Review Committee (PSPRC) meetings Review PQI's from all sources to determine the need for medical record review 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 position Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services) HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico. Active licensed RN in state of employment 3 years clinical RN experience 2 years of Utilization Review, Case Management, or Quality Management experience Strong analytical skills, experience manipulating and interpreting data Ability to work 7 - 4 p.m. E.T. or 8 - 5 p.m. E.T. Preferred Qualifications Accreditation (URAC, NCQA or JCAHO) experience Quality Management experience Work at Home Requirements 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 Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. 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. $71,100 - $97,800 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 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. 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. #J-18808-Ljbffr