Medicaid Quality Audit Professional 2 - Behavior Health
Company: Humana
Location: Metairie
Posted on: May 27, 2023
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Job Description:
Description
Humana Health Horizons in Louisiana is seeking Medicaid Quality
Audit Professionals - Behavior Health (BH) to ensure contracted
Specialized Behavioral Health Providers adheres to NCQA
documentation standards, BH Clinical Practice Guidelines and
Louisiana Department of Health's (LDH)Medicaid contractual
requirements. They will travel daily to and from provider offices
in their assigned regions to conduct on-site audits, provider
education, and collaboration with BH community resources. Each
Quality Audit Professional 2 will be assigned to specific regions
in the state of Louisiana.
Responsibilities
Responsible for coordinating on-site or desk top audits with BH
providers to include treatment record reviews, member interview and
provider education.
Utilize departmental tracking tools to request and retrieve
treatment record reviews; Store and retrieve records in accordance
with established procedures to ensure the timely access of
information and records.
Conduct ongoing monitoring of treatment records to ensure
appropriate utilization of health care resources for members though
review and analysis of documentation.
Prepares written results of oversight audits by communicating
findings, areas of concern and recommendations for improvement,
including corrective action requests in accordance with LDH's
strategies.
Conducts closing meetings with BH providers to give them a
preliminary overview of completed compliance audits.
Outreach to members and Providers via telephone or other method of
correspondence to assure care needs are being met and all
applicable data is received.
Follow-up and track Corrective Action Plan responses to ensure
implementation.
Participate in departmental and company meetings.
Document, investigate and resolve formal and informal complaints,
quality of care issues, and adverse events.
Develop and maintain audit schedules.
Train providers on auditing process and develop educational
material related to audit errors.
Other duties as assigned.
Required Qualifications
Must reside in Louisiana's Medicaid Regions 2, 4, 5 & the southern
cities in Region 6 (Click here to view region: LA Region Map
(https://ldh.la.gov/assets/docs/orgcharts/regionmap.jpg) ).
Ability to travel statewide in the state of Louisiana in assigned
regions and must be able to cover colleagues in other regions as
needed.
Unrestricted Licensed Mental Health Practitioner (LMHP) who is
licensed to practice independently in Louisiana and is in
compliance with the requirements of one of the following regulated
areas: Physicians (Psychiatrists), Medical Psychologists, Licensed
Psychologists, Licensed Clinical Social Workers (LCSWs), Licensed
Professional Counselors (LPCs), Licensed Marriage and Family
Therapists (LMFTs), Licensed Addiction Counselors (LACs) or
Advanced Practice Registered Nurses (APRN) with specialization in
adult psychiatric and mental health.
Minimum three (3) years of experience in behavioral health.
Must possess strong analytical skills.
Strong understanding of HEDIS/CMS/Joint Commission and other
national quality measures.
Demonstrated understanding of BH services, BH provider operational
processes, and provider's barriers and challenges to improved
quality of care.
This role is considered patient facing and is a part of Humana's
Tuberculosis (TB) screening program. If selected for this role, you
will be required to be screened for TB.
This role is a part of Humana's Driver Safety program and therefore
requires an individual to have a valid state driver's license and
proof of personal vehicle liability insurance with at least
100,000/300,000/100,000 limits.
Work at Home Requirements
At minimum, a download speed of 25 Mbps and an upload speed of 10
Mbps is recommended; wireless, wired cable or DSL connection is
suggested.
Satellite, cellular and microwave connection can be used only if
approved by leadership.
Humana will provide Home or Hybrid Home/Office associates with
telephone equipment appropriate to meet the business requirements
for their position/job.
Work from a dedicated space lacking ongoing interruptions to
protect member PHI / HIPAA information.
Preferred Qualifications
Experience in driving provider level quality improvement
initiatives and outcomes to achieve quality targets.
Strong understanding of quality improvement culture, behavioral
change models.
Additional Information
Workstyle: Remote with travel.
Travel: Up to 75% travel statewide in Louisiana in assigned regions
and must be able to cover colleagues in other regions as
needed.
Workdays/Hours: Monday - Friday; 8:00am - 5:00pm CST.
Benefits: Benefits are effective on day 1. Full time Associates
enjoy competitive pay and a comprehensive benefits package that
includes; 401k, Medical, Dental, Vision and a variety of
supplemental insurances, tuition assistance and much more.....
Vaccination Statement: Humana and its subsidiaries require
vaccinated associates who work outside of their home to submit
proof of vaccination, including COVID-19 boosters. Associates who
remain unvaccinated must either undergo weekly negative COVID
testing OR wear a mask at all times while in a Humana facility or
while working in the field.
Section 1121 of the Louisiana Code of Governmental Ethics states
that current or former agency heads or elected officials, board or
commission members or public employees of the Louisiana Health
Department (LDH) who work directly with LDH's Medicaid Division
cannot be considered for this opportunity. A separation of two (2)
or more years from LDH is required for consideration. For more
information please visit: Louisiana Board of Ethics (la.gov)
(https://ethics.la.gov/boardprocedures.aspx?type=advisory%20opinion)
Interview Format
As part of our hiring process, we will be using an exciting
interviewing technology provided by Modern Hire, a third-party
vendor. This technology provides our team of recruiters and hiring
managers an enhanced method for decision-making.
If you are selected to move forward from your application
prescreen, you will receive correspondence inviting you to
participate in a pre-recorded Voice Interview and/or an SMS Text
Messaging interview. If participating in a pre-recorded interview,
you will respond to a set of interview questions via your phone.
You should anticipate this interview to take approximately 10-15
minutes.
If participating in a SMS Text interview, you will be asked a
series of questions to which you will be using your cell phone or
computer to answer the questions provided. Expect this type of
interview to last anywhere from 5-10 minutes. Your recorded
interview(s) via text and/or pre-recorded voice will be reviewed
and you will subsequently be informed if you will be moving forward
to next round of interviews.
Social Security Task
Alert: Humana values personal identity protection. Please be aware
that applicants being considered for an interview will be asked to
provide a social security number, if it is not already on file.
When required, an email will be sent from Humana@myworkday.com with
instructions to add the information into the application at
Humana's secure website.
Scheduled Weekly Hours
40
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
https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Keywords: Humana, New Orleans , Medicaid Quality Audit Professional 2 - Behavior Health, Healthcare , Metairie, Louisiana
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