Senior Compliance Nurse

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.

Humana Healthy Horizons is seeking a Senior Compliance Nurse Professional who ensures utilization management and complex case management processes and procedures meet compliance with Centers for Medicare/Medicaid (CMS), each state Medicaid contractual requirements, and NCQA requirements. The Senior Compliance Nurse Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Research compliance issues and recommends changes that assure compliance with CMS, NCQA, and state contract obligations. Develop and implement process improvement initiatives and strategies with Quality and Compliance team to close compliance issues/gaps and mitigate risk, with focus on NCQA accreditation and state specific contractual requirements. Maintains relationships with Medicaid market Regulatory Compliance Professionals to ensure state specific contractual requirements are met regarding utilization management, complex case management, and clinical compliance. Create and maintain National Medicaid Compliance policies and procedures to ensure consistency across the Medicaid organization and decrease compliance risk. Create and maintain National Medicaid Policies for CCM and UM documentation to support NCQA requirements. Influences utilization management, complex case management, and clinical compliance department’s strategies and processes. Coordinates implementation and compliance with corrective action plans, as needed. Create new Medicaid market utilization management letters for state readiness review and submission based on contractual requirements. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.