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Description The Senior Quality Assurance, Clinical Professional requires being both a nurse/RN and a certified Coder nurse as this position will be cross trained to review DRG (Diagnosis Related Group) audits ..
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Description The Director, QOCA Strategy - serves as the strategic leader in resource utilization; budget and MER oversight; vendor oversight; and for clinician and non-clinician flex associates and off-shore vendor associates ..
Job Information Humana Medicaid Associate Director, Compliance Nursing in Dover Delaware Description The Associate Director, Compliance Nursing reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations ..
Description The Pre-Authorization Nurse 2 reviews Genetic testing prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The ..
Description The Medical Director relies on medical background and reviews health claims. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires ..
Description The Informaticist 2 coordinates with other analytics, IT and business areas across the organization to ensure work is completed with insights from knowledge SMEs. The Informaticist 2 work assignments are ..
... the development and implementation of quality improvement interventions and audits and ... years of experience in Accreditation, Quality Management, Compliance, Utilization Management, Behavioral ... degree Advanced degree in a..
Description The Staff Utilization Management Pharmacist is a clinical pharmacist who completes medical necessity and comprehensive medication reviews for prescriptions requiring pre-authorization. The Staff Utilization Management Pharmacist work assignments involve moderately ..
Description The Associate Director, Problem, Incident and Event Management drives technical support teams to recover services during periods of service disruption or outages to key technology platforms/applications. The Associate Director, Problem, ..
Description Come join the Digital Health & Analytics (DH&A) team within Humana to build a world class Data Science and Insights enterprise capability leveraging digital-first platforms, analytics, and agile development methodologies. ..
Description The Care Manager, Telephonic Nurse 2 , in a telephonic environment, assesses and evaluates members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and ..
Description The Senior Clinical Pharmacy Advisor - Trend, is a dynamic role within Humana. We are seeking a positive and proactive individual to contribute to a high performing team that helps ..
Description The Pharmacy Claims Lead operationalizes and monitors Coordination of Benefits (COB) and subrogation claim processing logic and processes. Exercises independent judgment and decision making on managing staff, complex issues regarding ..
... Member Plan (EFMP), auditing for quality and clinical compliance, and case ... compliance with ACD. Monitor for quality standards, claims accuracy, fraud, and ... Qualifications BCBA (Board Certified Behavior..
Description The Principal Quality Leader will lead testing and ... Leader will lead testing and quality collaboration between Business and IT, ... tools and assure adherence to quality standards. Serves..
Description Humana's Enterprise Clinical Management team needs your clinical, business and analytics acumen to solve for the healthcare challenges of today. The Clinical Analytics and Trend team uses advanced scientific techniques, ..
Description The Senior Medicaid Quality Data and Reporting Analyst generates ad hoc reports and ... factors. Responsibilities The Senior Medicaid Quality Data and Reporting Analyst will be responsible for the..
Description The Senior Provider Engagement, Clinical Professional develops and grows positive, long-term relationships with physicians, providers and healthcare systems in order to support and improve financial and quality performance within the ..
Description The Care Manager, Telephonic Behavioral Health 2 , in a telephonic environment, assesses and evaluates members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward ..
Description Responsibilities The Care Management Support Assistant 2- ACD Referral Coordinator-will process referrals from Military Treatment Facilities (MTFs) and civilian providers for the ACD program. The ACD Referral Coordinator performs varied ..
Description The Behavioral Health Parity Compliance Lead will play an integral role in the oversight and management of our Mental Health Parity Compliance Program. Responsibilities This role is responsible for monitoring ..
Description Be a part of an interactive team with broad exposure and scope within Humana. Humana is seeking a positive and proactive individual to contribute to a high performing team that ..
