Quality Assurance Professional

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

Comply, conduct, and summarize 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 as Home- and Community-Based Services (HCBS) service calculators and nursing facility level of care determination assessments to ensure accurate and consistent application of state and Humana guidelines.

Ensure Michigan Department of Health and Human Services (MDHHS), National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and Humana Gold-Plus Integrated 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 require minimal direction and receives guidance where needed.

Other duties as assigned by the LTSS leadership team.

Required Qualifications

Must reside in Michigan or within a 40-mile radius of the Michigan border in Ohio or Indiana.

Bachelor's degree.

Two (2) or more years of experience in care management, utilization management, quality assurance and/or population health supporting the Long-Term Services and Supports (LTSS) population.

Previous experience working with Managed Care Organization.

Proficiency in analyzing, tracking, and interpreting data trends to identify improvement opportunities and ensure adherence to operational guidelines, policies, and procedures.

Proficient with Microsoft Office products including Word Excel, Power Point, and Outlook.

Preferred Qualifications

Licensed healthcare professional in the state of Michigan: LPN, RN, LMSW, LBSW.

Previous Medicare/Medicaid, MDHHS, CMS, and NCQA experience.

Additional Information

Workstyle: This is a remote position.

Travel: Up to 10% travel, including occasional travel for audits, accreditation-related activities, and team engagement meetings at Humana's Detroit, Michigan location.

Typical Work Schedule: Monday through Friday; 8:00 AM to 5:00 PM Eastern Time (ET).

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.