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Description

The Senior Compliance Professional ensures compliance with governmental requirements. The Senior Compliance 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

The Senior Compliance Professional develops and implements compliance policies and procedures. Researches compliance issues and recommends changes that assure compliance with contract obligations. Maintains relationships with government agencies. Coordinates site visits for regulators, coordinates implementation and compliance with corrective action plans, as needed.

Key Responsibilities:

  • Serve as the subject matter expert on regulatory and accreditation requirements. Works independently with little need for guidance.
  • Serve as the subject matter expert on interpreting complex regulations, exercises independent judgement in applying Medicaid coverage guidelines, Humana Medical Coverage policies and MCG Guidelines into actionable and compliant UM determination templates. Independently monitors Medicaid coverage policy changes and presents recommended template changes based on changes in regulatory guidance. Makes recommendations involving other functions and other business units based on advanced knowledge and experience.
  • Independently facilitates groups of stakeholders in discussions and gains agreement on template format and content. Resolves any disagreements and/or clarifies ambiguous areas.
  • Chairs the Utilization Management Template Committee. Maintains minutes in an efficient manner that is audit ready.
  • Independently prepares documents and presents template recommendations to the committee for approval. Proactively identifies area of potential risk.
  • Review and analyze processes, documentation, and data to identify gaps and recommend solutions. Implement solutions as approved.
  • Partner with multiple stakeholders to develop compliant determination templates that are in accordance with established policies, regulatory and accrediting requirements.
  • Maintains an efficient system for storing, tracking and documenting updates to determination templates.
  • Identify new and emerging risks and develop plans to internally monitor and correct. Make recommendations to leadership.
  • Independently analyze audit results to determine any root causes, exercise judgement in development of action plans to address gaps, recommend process improvement activities for UM reviews, documentation requirements, procedural changes, opportunities for training or re-training of associates.
  • Collaborates effectively with trainers to implement optimal training. Prepares and conducts training of associates as needed.

Role Essentials:

  • RN with current active license with no disciplinary action
  • Minimum 5 years of demonstrated competence in utilization management. 
  • Excellent knowledge of Medicaid regulations and coverage policies.
  • Excellent knowledge of and experience in using MCG Guidelines.
  • Excellent PC skills (including MS Word, Excel, Access, PowerPoint and various platforms within Humana).
  • Excellent communication skills, written and verbal.
  • Excellent collaboration and facilitation skills across all levels of management and teams.
  • Strong analytical and problem-solving and assessment skills.
  • Be comfortable with electronic technology.  From the telephone to the computer, able to choose and adeptly use appropriate technology tools, methodologies and solutions.
  • Ability to work independently; be self-directed and motivated.

Role Desirables:

  • Strong presentation and facilitation skills
  • MCG certified
  • Knowledge of NCQA requirements
  • Experience working with physician determination language

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
  • Satellite, cellular and microwave connection can be used only if approved by leadership
  • Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
  • Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
  • Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Key Competencies:

  • Drives for Excellence: You are a continuous learner who encourages others to learn.  By constantly upgrading your own work, you achieve results and outperform the competition
  • Communication:  You actively listen to others to understand their perspective.  You understand that you must tailor your delivery according to your audience.  You are able to present information and/or recommendations verbally, graphically, and/or in writing that is articulate and succinct.
  • Implementation/Execution:  You are good at organizing and managing multiple priorities and/or projects by using appropriate methodologies and tools.

Scheduled Weekly Hours

40



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Our Hiring Process

Apply online

To be considered for a job, you must apply online. Unfortunately, we cannot accept resumes that have been emailed to us. Once you find a job that interests you, simply select “Apply.” It typically takes 15 minutes to fill out the application form. Be sure to update your resume and upload it as you cannot edit the resume or add it after the application has been submitted. Shortly after you submit your application, you will receive a confirmation.

Next Step

If selected to continue with the interview process, you will be contacted through text or email to complete an assessment or schedule an initial live or recorded phone or video interview.

A hiring manager interview

After hiring managers and interview teams carefully consider the skills and experiences of applicants, they contact the top candidates via email or phone to schedule an interview.

Offer from Humana

If you’ve successfully completed the interview process and are identified as the candidate we would like to hire, you will receive an offer from our Talent Acquisition team.

Onboarding

If you accept the offer to join our Humana team, you will receive a welcome call or email to begin the onboarding process.


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Hiring Process