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 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.
- 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
- Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
- Proficient with Microsoft Office products including Word, Excel and Outlook
- Ability to work independently under general instructions and with a team
- Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems if 10Mx1M
- Education: BSN or Bachelor’s degree in a related field
- Knowledge of CMS regulations a plus
- Previous experience in utilization management, discharge planning and/or home health or rehab
- Health Plan experience
- Previous Medicare/Medicaid Experience a plus
- Experience working with MCG or Interqual guidelines
- Hours for this role are: Monday-Friday 8:30am-5:30pm CST.
- This role also has Mandatory On-Call rotation for weekends and holidays.
Scheduled Weekly Hours40