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

The Quality Audit Professional collects and reviews records, summarizes issues, works with Medical director, and implements corrective actions as needed. Coordinate Peer review committees. Audits quality cases for compliance. Understand department, segment, and organizational strategy and operating goals, 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.

Comprehensive medical reviews will be conducted on applied behavior analysis providers' claims for all BH specified CPT codes, coordination of care and services

Use your skills to make an impact
 

Required Qualifications

• Must reside in the Commonwealth of Virginia.
• Master's level clinician, current, valid, and unrestricted license as a Mental Health (MH)/Behavioral Health (BH) Professional in at least ONE of the following: Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Mental Health Counselor (LMHC), Licensed Masters Social Worker (LMSW) AND/OR Clinical Psychologist (Ph.D.).
• 2 years of professional experience in quality assurance, quality compliance or quality improvement within managed care health plan organization.
• Experience utilizing MCG and American Society of Addiction Medicine Criteria
• 1 or more years of professional experience in medical audits and medical record reviews.
• Comprehensive knowledge of Microsoft Word, Excel and PowerPoint.
• Excellent communication skills, both oral and written.
• Strong relationship building skills.
• Ability to travel to region-based providers to perform quality onsite audits and medical reviews. (10-20% --- potentially quarterly)
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

Preferred Qualifications

• 2 years of direct care experience in an acute or outpatient behavioral health setting
• 2 years community-based services experiences
• Experience with Utilization Management or Prior Authorization
• Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Will speak, read and write in both languages without limitations and assistance. See "Additional Information" section for more information.

Additional Information

Work at Home Internet Criteria

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 recommended; wireless, wired cable or DSL connection is suggested.

• Satellite, cellular and microwave connection can be used only if approved by leadership.

• Employees 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 employees 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.

Interview Format

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

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.

 

$71,100 - $97,800 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
 

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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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.