DescriptionThe Compliance 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 Compliance Nurse 2 ensures member case management, reporting, and compliance se it relates to CMS standards. Collects and analyzes data related to member health status needs to assess outcome. Meets operational metrics standards 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. Follows established guidelines/procedures.
- Bachelor's degree
- Less than 5 years of technical experience
- Active RN license in the state(s) in which the nurse is required to practice
- Ability to be licensed in multiple states without restrictions
- A minimum of three years varied nursing experience
- Proficient with Microsoft Office products including Word, Excel and Outlook
- Ability to work independently under general instructions and with a team
- BSN or Bachelor's degree in a related field
- Health Plan experience working with large carriers
- Previous Medicare/Medicaid experience a plus
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab
- Certification in Case Management a plus (CCM)
- Experience working with MCG or Interqual guidelines
Scheduled Weekly Hours40