Compliance Nurse 2 - IL Medicaid - RN Remote

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Job Information
Humana
Compliance Nurse 2 - IL Medicaid - RN Remote
in
Chicago
Illinois
Description
The 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.
Responsibilities
The Compliance Nurse 2 ensures mandatory reporting is 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.
Conducts clinical reviews for Provider Disputes for Acute Inpatient cases.
Required Qualifications
Unrestricted Active RN license in the state of Illinois without any disciplinary action
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
Hours for this role are: Monday-Friday 8:30am-5:30pm CST. This role also has mandatory On-Call rotation for weekends and holidays.
Work At Home Requirements
Must have a separate room with a locked door that can be used as a home office to ensure you and your members have absolute and continuous privacy while you work.
Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.
Screening Requirements
We will require full COVID vaccination (**** for this job as 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 documentation for a medical or religious exemption consideration where allowed by law. Requests for these exemptions should be submitted at least 2 week prior to your scheduled first day of work.
Preferred Qualifications
Education: BSN or Bachelor's degree in a related field
Health Plan experience
Previous Medicare/Medicaid experience a plus
Previous experience in utilization management, discharge planning and/or rehab
Familiarity with regulatory guidelines including CMS and NCQA
Experience working with MCG guidelines
Additional Information
Interview Format
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Modern Hire Voice 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.
If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed)
inviting you to participate in a Modern Hire Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
40

Company info

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