The Associate Director, 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. The Associate Director, Compliance Nursing requires a solid understanding of how organization capabilities interrelate across department(s).
As Humana’s Medicaid membership continues to grow, the National Medicaid Clinical Operations team is expanding our shared services organization to enhance the clinical delivery process. The Associate Director, Compliance Nursing ensures mandatory reporting completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s), and could lead multiple managers or highly specialized professional associates.
The **_Associate Director, Compliance Nursing_** will be responsible for developing and implementing centralized functions and services to support 24/7 clinical operations delivery, Preauthorization List development and governance, Mental Health Parity, Clinical compliance, and quality performance and staffing management.
**_Detailed Responsibilities include:_**
Leads Medicaid operational process and workforce management for Centralized Clinical Operations delivery including:
+ Developing state-level Preauthorization Lists for each Medicaid state, providing routine analysis, and ongoing system updates to administer operations according to the Preauthorization List;
+ Assure clinical compliance with Mental Health Parity regulations and lead clinical workgroups for Mental Health Parity analysis for each state;
+ Implement Performance Management operational resources and tools across clinical teams in Medicaid markets and centralized clinical Utilization Management team, to assure efficient processes are in place;
+ Support development of national clinical staffing models and work with Medicaid markets to support staffing model revisions;
+ Implement Utilization Management and Care Management Compliance Audit team to assure high quality and compliant care is delivered across Medicaid;
+ Implementing and hiring a 24/7 clinical support team for ability to make Utilization Management decisions and provide access to Care Management support 7 days per week, 24 hours per day;
+ Develop IT system requirements and claims edit rules for administering Preauthorization List and 24 hour/7 day per week clinical support;
+ Collaboratively develop Reporting requirements to assure operational oversight and address state reporting requirements for supporting all Medicaid state
+ Participate in on-call rotation program to provide after hours, 24/7 clinical coverage requirements.
*Bachelor’s Degree in health or business related field;
*Active clinical RN licensure required **_;_**
*7+ years of Clinical Services program implementation, process improvement and delivery experience
*6+ years of Managed Care or health industry experience
*6+ years of operational leadership experience and compliance-related background
*2+ years of Quality Management, Performance Management, and staffing model oversight experience
*Previous Medicaid experience
*5+ years developing collaborative partnerships with enterprise cross-functional teams
*Previous Preauthorization List development and Mental Health Parity knowledge and experience
*Recent working knowledge and familiarity with NCQA and Medicaid policy guidelines
*Demonstrated experience and recommendations from peers as a customer-focused, team player, with collaborative approach to leading is
*Ability to participate in on-call rotation program to provide 24/7 clinical coverage requirements
*Master’s Degree in Nursing or Business-related field.
This position is open to working remote and have the ability to work and support eastern time zone.
**Scheduled Weekly Hours**
13 hours ago