RN Auditor, Utilization Management/Clinical Compliance - Doral, FL

Humana Inc. Miami , FL 33196

Posted 10 months ago

Description

The Compliance/Audit 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 hours of this role are Mon-Fri, 8am-5pm est. The work location will be the office in Doral. FL for the first 6 months and will then transition to work at home with the flexibility to work from home 2 days a week Occasional overtime as needed based on the needs of the business.

The Compliance/Audit Nurse 2 ensures mandatory reporting 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.

Required Qualifications

  • Active RN license in FL without restrictions

  • Ability to be licensed in multiple states without restrictions

  • Prior clinical experience in an acute care, skilled or rehabilitation clinical setting

  • Experience in utilization management

  • Excellent computer skills and ability to easily navigate multiple applications

  • Strong communication skills, both verbal and written

  • Ability to work independently under general instructions and with a team

Preferred Qualifications

  • BSN or Bachelor's degree in a related field

  • Health Plan experience working with large carriers

  • Previous experience as a UM Auditor

  • Experience working with MCG guidelines

  • Strong preference for bilingual (able to read and write in Spanish)

Additional Information

As part of our hiring process for this opportunity, we will be using a technology called Montage Voice which allows us to quickly connect and gain valuable information from you about your relevant experience.

If you are selected for a phone screen you will receive an email inviting you to participate in a Montage Voice interview. During this call you will be asked a set of questions pertaining to this particular role and you will provide recorded responses. The entire process takes about 15-20 minutes and can be done at your convenience. Your responses will be reviewed and you will be informed if you were selected for an in person or video interview, depending on your location.

Scheduled Weekly Hours
40


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RN Auditor, Utilization Management/Clinical Compliance - Doral, FL

Humana Inc.