Humana

About Humana

 

Job Category:

Member Quality & Financials - Utilization Management

Country:

United States

Postal Code:

11415

Approximate Salary:

Not Specified

Position Type:

Full Time

Clinical Compliance Nurse 2 (UM Auditor) - Doral, FL

Humana - Kew Gardens, New York

Posted: 08/31/2018

Description

The Compliance/Audit 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.

Responsibilities

The hours of this role are Mon-Fri, 8am-5pm est. The work location will be the office in Doral. FL for the first 6 months and will then transition to work at home.

The Compliance/Audit 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. Follows established guidelines/procedures.

               

Required Qualifications

  • Active RN license in FL without restrictions
  • Ability to be licensed in multiple states without restrictions
  • Prior clinical experience in an acute care, skilled or rehabilitation clinical setting

  • Experience in utilization management

  • Excellent computer skills and ability to easily navigate multiple applications
  • Strong communication skills, both verbal and written
  • Ability to work independently under general instructions and with a team

Preferred Qualifications

  • BSN or Bachelor's degree in a related field
  • Health Plan experience working with large carriers
  • Previous experience as a UM Auditor
  • Experience working with MCG guidelines
  • Strong preference for bilingual (able to read and write in Spanish)

Additional Information

Scheduled Weekly Hours

40

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