Remote
Humana

Quality Audit Professional 2

Phoenix, AZ
Work at Home

Description

The Quality Audit Professional 2 analyzes and investigates quality issues. The Quality Audit Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Quality Audit Professional 2 collects and reviews records, summarizes issues, works with Medical director as needed, and implements corrective actions as needed.

  • Coordinates Peer review committees.
  • Audits quality cases for compliance.
  • 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.

Implements Quality Operations Compliance & Accreditation Program in assigned divisions for all lines of business including Medicare, Commercial, Duals, Medicaid and Special Needs Plans and for multiple products including POS, HMO, PPO, PFFS, ASO, etc.

Required Qualifications

  • 3-5 years clinicaland/orhealth plan experience including 2 years of behavioral health experience
  • RN active unrestricted license
  • Strong oral / written communication and presentation skills
  • Strong analytical skills, able to manipulate and interpret data
  • Office practice / hospital experience
  • Organizational and prioritization skills
  • Comprehensive knowledge of Microsoft Office Word, Excel and PowerPoint
  • This role is part of Humana’s Driver safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100/300/100 limits

Preferred Qualifications

  • Bachelor’s degree
  • Knowledge of HEDIS/Stars/CMS/Quality
  • Previous quality or process improvement experience in a hospital or physician office practice
  • Strong business skills, including sales and marketing objectives
  • Detail orientated and comfortable working with tight deadlines in a fast paced environment
  • Ability to work independently under general instructions, self-directed and motivated

Scheduled Weekly Hours: 40