Quality Assurance

This is a fully remote position, open to applicants in Ohio, +1 more state.

📋 Description

• Review the documentation and performance of Long-Term Services and Support (LTSS) contractors to ensure compliance with the contract's scope of work and relevant state and federal regulations.

• Guarantee adherence to policies, procedures, and regulations while working to prevent and identify fraud, waste, and abuse.

• Execute and summarize compliance audits and reports, highlighting deficiencies and risks.

• Gather and review records, summarize issues, and analyze data to evaluate outcomes and operational metrics.

• Conduct inter-rater reliability audits for vendor activities, including HCBS service calculators and assessments for nursing facility level of care determinations.

• Ensure that MDHHS, NCQA, CMS, and Humana Gold-Plus Integrated policies and procedures are strictly followed.

• Complete audits in a timely manner and communicate findings to leadership.

• Make informed decisions regarding work methods in situations that may be ambiguous, requiring minimal guidance.

• Perform additional duties as assigned by the LTSS leadership team.

• Occasionally travel to Humana offices for training sessions, meetings, audits, accreditation-related activities, and team engagement.

⛳️ Requirements

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

• Bachelor’s degree is required.

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

• Prior experience working with a Managed Care Organization is preferred.

• Strong skills in analyzing, tracking, and interpreting data trends to identify opportunities for improvement and ensure compliance with operational guidelines, policies, and procedures.

• Proficient in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.

• Preferred: Licensed healthcare professional in the state of Michigan (LPN, RN, LMSW, LBSW).

• Preferred: Previous experience with Medicare/Medicaid, MDHHS, CMS, and NCQA.

• Up to 10% travel may be required, including occasional trips for audits, accreditation-related activities, and team engagement meetings.

• Availability from Monday to Friday, 8:00 AM to 5:00 PM Eastern Time.

• Minimum home internet speed of 25 Mbps download and 10 Mbps upload is required.

• A dedicated workspace free from ongoing interruptions is necessary to protect member PHI/HIPAA information.

🏝️ Benefits

• Bonus incentive plan based on individual and/or company performance.

• Medical benefits are provided.

• Dental benefits are included.

• Vision benefits are available.

• 401(k) retirement savings plan offered.

• Paid time off is provided.

• Company holidays are observed.

• Personal holidays are included.

• Paid parental leave is available.

• Paid caregiver leave is offered.

• Short-term disability coverage is included.

• Long-term disability coverage is provided.

• Life insurance is available.

• Wellness support and smart healthcare decision-making assistance are offered.

• Remote work arrangement is supported.