Senior Quality Audit Professional

Profile

Description

The Senior Quality Audit Professional analyzes and investigates quality issues. The Senior Quality Audit Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

Location: work at home anywhere

The Senior Quality Audit Professional acts as Quality Case Investigation Subject Matter Expert, with emphasis on Intake and Triage of new cases for all lines of business including Medicare, Medicaid, Duals, Commercial, Special Needs Plans, and for multiple products including POS, HMO, PPO, ASO, etc.

Communicates with external providers to ensure appropriate records and dates of service (DOS) are included for the case

Escalates the case to HMD and Manager as needed for cases that require oversight based on risk

Identifies and determines the initial risk stratification level.

Completes assessment of member allegation and researches internal systems to determine the appropriate risk level

Accurately identifies the appropriate records for retrieval based on the referral information in QMS

Assumes manager role in absence of QI Manager as needed

Understands and keeps up with policy updates impacting process changes to cases.

Trains Quality Operations Compliance & Accreditation staff and Medical Directors as needed

Participates in required audits to meet accreditation and regulatory requirements

Required Qualifications

Bachelor's degree or equivalent work experience

Registered Nurse

5 years or more of clinical experience

Experience with quality of care investigations

Understanding of healthcare quality measures STARS, HEDIS, etc.

Comprehensive knowledge of Microsoft Office Word, Excel and PowerPoint

Proven analytical skills

Excellent communication skills, both oral and written

Strong relationship building skills

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Desired Qualifications

Knowledge of Humana's internal policies, procedures and systems

Additional Information

Humana is an organization with careers that change lives-including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you're ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com