RN Compliance Auditor

5 days ago

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Humana

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10,000+

Description

• Reviews utilization management activities and documentation to ensure adherence to policies • Prevents and detects fraud, waste, and abuse • Conducts and summarizes compliance audits • Collects and analyzes data to assess operational metrics • Performs pre-service denial and quality assurance audits • Makes necessary revisions to member denial letters for compliance • Analyzes authorizations and medical records for regulatory compliance • Responsible for internal and external communications for audit functions • Recommends process changes or training opportunities • Coordinates special compliance projects and additional tasks from leadership

Requirements

• Current Unrestricted Florida RN license or Compact RN License • Experience with Utilization Management and Quality assurance audits • Clinical experience in an Acute Care • Proficiency in Microsoft Office Products Word, Excel, and Power Point • BSN or Bachelor's degree in a related field (preferred) • Bilingual (English, Spanish) (preferred) • Experience as a utilization management Auditor (preferred) • Health Plan experience working with large carriers (preferred) • Experience working with MCG/Interqual guidelines (preferred) • Excellent computer skills and ability to easily navigate multiple applications (preferred)

Benefits

• Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Volunteer time off • Paid parental leave • Caregiver leave • Short-term disability • Long-term disability • Life insurance • Many other opportunities