Unknown Company is hiring a Quality Audit Professional

Humana is looking for a Quality Audit Professional 2 to join our team. In this role, you will analyze and investigate quality issues, providing essential support for our Clinical Quality Management Program. Become a part of our caring community and help us put health first.

What You'll Do

• Analyze and investigate quality issues.
• Support the Healthcare Quality Management Team in administering and implementing the Clinical Quality Management Program (CQMP).
• Collect and review records, summarize issues, work with Medical Director as needed, and implement corrective actions as assigned.
• Review medical records, create case summaries, and present potential quality issue (PQI) cases to Medical Director for review.
• Provide assistance to Medical Directors to ensure corrective action plans (CAPs) are developed and implemented.
• Monitor CAP for timeliness, and enter data into the Provider Trending Database according to Policy and Procedure.
• Monitor cases entered in the Clinical Quality Management Database (CQMD) for accuracy, timeliness of completion, and documentation.
• Participate 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.
• Participate in departmental projects such as focused reviews as available.
• Make decisions regarding own work methods, occasionally in ambiguous situations.
• Follow established guidelines and procedures.

What We're Looking For

• U.S. citizenship (Department of Defense Contract requirement).
• Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services).
• Cannot be living in Puerto Rico per government contract.
• 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.

Nice to Have

• Accreditation (URAC, NCQA or JCAHO) experience.
• Quality Management experience.

Team & Environment

Supports the Healthcare Quality Management Team.

Benefits & Compensation

• Compensation: $71,100 - $97,800 per year
• 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.
• Bonus incentive plan based on company and/or individual performance.
• Bi-weekly internet expense payment for associates in California, Illinois, Montana, or South Dakota.
• Telephone equipment provided.

Work Mode

This is a remote position.

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.