Manager, Compliance Nurse

Job Overview The Manager, Compliance Nursing reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. Reporting to the Clinical Strategy and Practice Director, you will work within specific guidelines and procedures; apply advanced technical knowledge to solve moderately complex problems; receive assignments in the form of objectives and determine approach, resources, schedules and goals. Responsibilities Maintain NCQA accreditation and state contractual requirements with passage of UM standards, including timeliness of determinations, appropriateness of decision making and documentation in CGX and letters Ensures team meets all assigned work completion and submission deadlines (i.e. letters, provider notification of decision, and reports); trends results to identify improvement opportunities Align procedures to improve associate productivity and quality to broaden role responsibilities for optimal outcomes Improve associate experience and member outcomes through innovation, identifying new ways of working using technology enhancements to streamline processes and create administrative efficiencies Requires cross departmental collaboration, and conducts briefings and area meetings, maintaining frequent contact with other managers across the market Required Qualifications Active Licensed Registered Nurse (RN) in your state of residence without disciplinary action and ability to obtain multiple licenses 2+ years of compliance experience 2 years team lead, coaching, subject matter expert, and/or project leadership experience 1 year of Utilization Management experience Proficiency using Microsoft Office Word, Excel, PowerPoint Preferred Qualifications Associate's Degree Management experience Compact licensure Behavioral Health Utilization and/or Case Management experience which may include working knowledge of Interqual, MCG, ASAM NCQA UM Behavioral Health Accreditation Requirements Workstyle and Schedule Remote. 40‑hour work week Monday‑Friday 9:00‑6:00 PM or 8:30‑5:30 Eastern Time.

Travel 1‑2 times annually for onsite meetings. Occasional travel to Humana offices for training or meetings may be required. Compensation $86,300 – $118,700 per year.

This job is eligible for a bonus incentive plan based upon company and/or individual performance. Benefits Humana, Inc. and its affiliated subsidiaries offer competitive benefits that support whole‑person well‑being. Associate benefits include medical, dental and vision, a 401(k) retirement savings plan, paid time off (including paid holidays, volunteer time off, paid parental and caregiver leave), short‑term and long‑term disability, life insurance and many other opportunities.

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.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our accessibility resources . #J-18808-Ljbffr