Health Services Compliance Manager - Remote EST Zone

Profile

Description

The Manager, Compliance (UM) conducts and summarizes compliance audits. This role works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.

Responsibilities

The Manager, Compliance (UM) collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. Ensures mandatory reporting completed. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.


The Compliance manager will oversee clinical and non-clinical compliance associates that analyze compliance requirements, provide research and regulatory interpretation, and advise the internal operational areas within the CarePlus Health Services Organization (HSO) in delivering results in a manner that minimizes compliance risk exposure for the organization.
Interpret and define regulatory and contract requirements to be implemented by the appropriate HSO departments.
Responsible for completing risk assessments, creating annual work plans to audit and monitor utilization management to ensure full compliance and minimize risk for the organization.
Maintain detailed knowledge of audit protocols & regulatory requirements affecting audits.
Lead remediation of internal and external audit findings - provide recommendations to drive change and follow-up to ensure plans are implemented timely and effectively.
Facilitates and participates in meetings and workgroups and serves as a compliance subject matter expert for CarePlus HSO.


Required Qualifications


Current Unrestricted RN licensed in the state in which you reside with no disciplinary action.
3 or more years of prior experience in auditing, compliance oversight, and/or utilization management for an insurance health plan.
3 or more years of direct leadership experience (as defined by having direct reports) to include hiring, training, coaching and up to termination.
Knowledge of regulations governing the Medicare line of business.
Proficient in Microsoft Office applications including Word, Excel, Outlook and PowerPoint.
Strong problem solving, data-analysis, and critical-thinking skills with the ability to operate and drive progress with limited information and ambiguity.
Work hours for this position are 8AM- 5 PM Monday- Friday Eastern Time, with occasional overtime to support business needs.
Training: Virtual training, approximately 3 months
This is a Remote position, you will be expected to work in Eastern time zone regardless of what time zone you reside in.
You will be expected to report to the Market office with advanced notice for meetings and/or planned work functions.
Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.


Work At Home Requirements


WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information


referred Qualifications


Bachelor Degree
Certification(s) relevant to area of expertise, such as certification in healthcare compliance (CHC).
Prior Medicare health plan experience.
Experience working with and interpreting CMS regulations and criteria.


Additional Information

Onsite Travel

In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves. The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process.

#ThriveTogether #WorkAtHome

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. (please be sure to check your spam or junk folders often to ensure communication isn't missed) If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

ur recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Company info

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