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 determines approach, resources, schedules and goals.
Responsibilities include:
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
Use your skills to make an impact
Required Qualifications
o Active Licensed Registered Nurse (RN) in your state of residence without disciplinary action and ability to obtain multiple licenses.
o 2+ years of compliance experience
o 2 years team lead, coaching, subject matter expert, and/or project leadership experience
o 1 year of Utilization Management experience
o Proficiency using Microsoft Office Word, Excel, PowerPoint,
Preferred Qualifications
o Associate's Degree
o Management experience
o Compact licensure
o Behavioral Health Utilization and/or Case Management experience which may include working knowledge of any or all the following, Interqual, MCG, ASAM
o NCQA UM Behavioral Health Accreditation Requirements
Additional Information
· Workstyle: Remote
· Schedule: 40-hour work week Monday through Friday 9:00 to 6:00 PM or 8:30-5:30 Eastern Time
· Travel: 1-2 times annually for onsite meetings
Interview Format
As part of our hiring process for this opportunity, we will use an interviewing technology called HireVue to enhance our hiring. HireVue allows us to quickly connect and gain valuable information from you about your relevant 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
40Pay 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.
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.Application Deadline: 04-17-2026About 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.
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.
Top Skills
What We Do
At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.
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