At Shire, we are proud and grateful to employ military veterans and thank them for their contributions to our company and our country. See where your military experience can play a role at Shire by using our military skills translator job search tool below:
Become a part of our caring community and help us put health first
The Senior Quality Assurance Clinical Professional may assist with the development of policies, procedures, and methods to ensure operational quality and compliance standards are met. The Senior Quality Assurance, Clinical Professional, supports and implements programs to establish high quality standards in clinical products and services. They will collaborate with the manager and other leaders in training, coaching, and management in areas such as quality improvement and process management. Maintains communications with administration, medical staff and other disciplinary departments regarding quality assurance activities. The Senior Quality Assurance Professional will make decisions on moderately complex to complex issues regarding technical approach for project components. Work assignments are varied and will require interpretation and independent determination of appropriate courses of action.
You will provide support to the Healthcare Quality Reporting and Improvement (HQRI) Provider Support Team (PST) in developing and completing quality assurance check points for all HQRI PST initiatives. This position is accountable for producing a quality assurance framework that aligns with corporate strategies for HQRI and may work in collaboration with other departments.
Position Responsibilities
Ensures mandatory reporting completed.
Supports and implements programs to establish high quality standards clinically.
Collaborates with leaders in training, coaching, and management for quality and process improvement.
Will assist the compliance audit nurse with complying, conducting, and summarizing audits/reports to include deficiencies and risks for compliance.
Summarizes issues and analyzes data daily, weekly, monthly, or as needed to assess outcome and operational metrics.
Support, develop and operationalize methods to drive program and service consistency.
Proficiency in analyzing, tracking, and interpreting data trends for operational readiness and maintaining state and federal compliance.
Ensures DMAS Cardinal Care Guidelines, NCQA, CMS, and Humana's Healthy Horizon's Policy and Procedures are followed.
This is mainly a virtual position, however, it may require occasional travel for meetings or audits to ensure accreditation is met.
Ensures timeliness of work and stays in communication with leadership as needed.
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal to no direction and receives guidance where needed.
Other duties as assigned per CM or Quality leadership.
Use your skills to make an impact
Required Qualifications
Active Registered Nurse license in the state of Virginia or obtain a multi-state license that participates in the enhanced compact licensure, (eNLC) without disciplinary action
Minimum three, (3) years clinical experience preferably in an acute, skilled or rehabilitation setting
Minimum three, (3) years of care management nursing experience
Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment
Previous experience with Managed Care Organization, with knowledge of Medicaid and Medicare.
Quality Assurance, compliance and/or auditing experience.
Ability to work independently under general instructions and with a team.
Exceptional oral and written communication & interpersonal skills with the ability to build rapport with internal and external customers and stakeholders.
Preferred Qualifications
Bachelor’s degree in nursing
Previous DMAS, CMS, HEDIS, and NCQA experience
General nursing experience (Med/Surg, ED, ICU preferred)
Inpatient and outpatient medical record review and auditing experience.
Workstyle: Remote work at Home
Location: Virginia or reside within 40 miles of one of the following contiguous bordering states - Tennessee, West Virginia, North Carolina, Maryland, or Kentucky
Schedule : Monday - Friday 8:00 AM to 5:00 PM Eastern
Travel: 25% travel within the Commonwealth of Virginia for meetings or compliance assurance audits
Work at Home/Remote Requirements To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria: at minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
SSN Alert Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.
Interview Format As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$86,300 - $118,700 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.
About us
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.
Equal Opportunity Employer
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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.