HCS Compliance amp Risk Management Quality Audit QA Risk Management Professional 2-Remote US

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Job Information
Humana
HCS Compliance & Risk Management Quality Audit (QA) Risk Management Professional 2-Remote, US
in
Portland
Maine
Description
The Risk Management Professional 2 identifies and analyzes potential sources of loss to minimize risk. The Risk Management Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Responsibilities
As a HCS Compliance & Risk Management Quality Audit (QA) Risk Management Professional 2, you will be responsible for executing the Compliance Oversight QA program for Delegates/Vendors performing Utilization Management. Identifies concerns and works with clinical operations to determine a resolution. Develops and implements controls and cost-effective approaches to minimize the organization's risks. Assesses and communicates information regarding business risks with functions across the organization. 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.
Primary responsibilities for the Quality Auditor will include:
Collaborate with the Quality Audit (QA) Manager to design and implement the QA function:
Work with Operations and Compliance teams to assess risks and establish an Oversight QA work-plan to address those risks on a proactive basis
Establish sampling methodology and audit criteria for each quality audit on the QA work-plan, based on compliance and operational risks, known issues, and relevant internal/external requirements
Define requirements for the quality audit tool and perform user acceptance testing
Execute quality audits per defined audit criteria and document results in the quality audit tool; perform root cause analysis on audit findings and provide recommendations for risk mitigation and issue remediation.
Perform testing of internal control procedures per defined audit attributes and document results; perform root cause analysis on findings and provide recommendations for enhancements to existing controls.
Assist with the development and maintenance of an audit findings tracking tool to ensure each finding is communicated to key stakeholders and a course of action is established/implemented.
Participate in ongoing risk assessment discussions to identify strategic, operational, and compliance opportunities and update the QA work-plan accordingly.
Adhere to productivity and accuracy standards as established by management
Required Qualifications
Registered Nurse
2 years of experience in an audit-based or compliance oversight role, including documentation of findings according to a defined methodology
Knowledge of regulations governing the health care industry (CMS or Medicare and/or NCQA accreditation)
Experience building positive cross-functional relationships and communicating issues in a constructive manner
Extremely detail-oriented and committed to accuracy
Demonstrated ability to operate independently and apply strategic thinking to task-oriented work
Proficiency using Microsoft Word, Excel, PowerPoint, Outlook
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
Bachelor's degree in Nursing
Experience identifying and testing internal control procedures according to an audit methodology
Knowledge around utilization management delegation
CMS universe knowledge
Experience utilizing a database tool such as Microsoft Access
Familiarity with Humana's Clinical Guidance Exchange (CGX)
Additional Information
WAH - Nationwide (or can work onsite in Louisville if preferred)
For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to:
Provide proof of full vaccination or commit to testing protocols
*OR  *
Provide proof of applicable exemption including any required supporting documentation
​​Medical, religious, state and remote-only work exemptions are available.
Interview Process
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
40

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