QA External LTSS Oversight Professional - Remote Eligible

Quality Assurance Professional

The Quality Assurance Professional reviews LTSS contractor documentation and performance to ensure compliance with contract scope of work, and state and federal regulations. The Quality Assurance Professional ensures adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse to ensure appropriate course of action. The Quality Assurance Professional understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Quality Assurance Professional work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

• Complies, conducts, and summarizes compliance audits/reports to include deficiencies and risks.
• Collect, review records, summarize issues and analyze data daily, weekly, monthly, or as needed to assess outcome and operational metrics for the team and individuals.
• Conduct inter-rater reliability audits for multiple vendor activities such HCBS service calculators and nursing facility level of care determination assessments to ensure accurate and consistent application of state and Humana guidelines.
• Proficiency in analyzing, tracking, and interpreting data trends, operational guidelines and procedures are adhered to.
• Ensure MDHHS, NCQA, CMS, and Humana’s Healthy Horizon’s Policy and Procedures are followed.
• Ensure auditing is completed timely and communicated with leadership.
• Make decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Other duties as assigned per CLTSS leadership team.

Use your skills to make an impact.

Required Qualifications

• Must reside in the state of Michigan or within 40 miles of the border in Indiana or Ohio.
• Bachelor’s degree in social work or nursing (unlicensed)
• A minimum of 2 years’ experience in LTSS.
• Proficient with Microsoft Office products including Word, Excel, PowerPoint, and Outlook.
• Previous experience with Managed Care Organization.
• Ability to work independently under general instructions and with a team.
• Exceptional oral and written communication and interpersonal skills.
• This is a mainly a virtual position, however, it may require occasional travel for meetings or audits to ensure accreditation is met and as such the ability to travel as needed is necessary.

Preferred Qualifications

• Licensed healthcare professional in the state of Michigan: LPN, RN, LSW, LISW.
• Previous Medicare/Medicaid, MDHHS, CMS, and NCQA experience.

Additional Information

Workstyle: This is a remote position.

Travel: This is a mainly virtual position, however, it may require occasional travel for meetings or audits to ensure accreditation is met and as such the ability to travel as needed is necessary.

Workdays and Hours: Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST).

Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

Scheduled Weekly Hours 40

Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $65,000 - $88,600 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.