Compliance UM Nurse (Wed - Sun)

Become a part of our caring community   The Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Please Note: This role will follow a four-day, 10-hour shift schedule within a Wednesday through Sunday work week. The assigned schedule will be either Wednesday through Saturday or Thursday through Sunday, with work hours scheduled between 8:00 a.m. and 8:00 p.m. Eastern Time. T he Compliance Nurse 2   c ollects and analyzes data daily, weekly,   monthly   or as needed to assess outcome and operational metrics for the team and individuals. Understands department, segment, and organizational strategy and operating   objectives , including their linkages to related   workstreams . Makes decisions   regarding   own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.   Assignments are varied and often complex, requiring independent judgment, critical thinking, and interpretation of guidelines to determine   appropriate courses   of action.   Follows established guidelines , regulatory turnaround times, and   procedures   for processing QIO fast track appeals and expedited authorization requests .  Use your skills to make an impact   Required Qualifications       Licensed Registered Nurse (RN) in a compact state with no disciplinary action.      Must have  valid  compact license or  reside  in a compact state and be eligible to upgrade to compact licensure.      Three (3) or more years of consecutive UM experience for a health plan OR two (2) or more years of consecutive UM auditing experience in a traditional Quality or Compliance role at a health plan OR one (1) or more years of home health  utilization  management experience for a health plan      Effective telephonic and virtual communication skills      Comprehensive knowledge of Microsoft Word,  Outlook  and Excel      Ability to work independently under general instructions and within a team.      Must be passionate about contributing to an organization focused on continuously improving consumer experiences         Preferred Qualifications       The ideal candidate for this opening would be a current member of the One Home / Home Solutions UM Team who has been in their current position for 12+ months     Bachelor’s degree in nursing or related field     Clinical experience in a home health and/or Skilled Nursing Facility setting     Clinical experience working QIO appeals,   expedited   request reviews and/or compliance   Health Plan experience          Additional Information       This position is within a department that   operates   in EST.   This position offers a flexible schedule of Monday to Sunday, between 8 am and 8 pm EST with occasional overtime.   This position follows a 4-day workweek consisting of ten-hour shifts, available schedules include:    Wednesday - Saturday Thursday - Sunday       Work-At-Home Requirements       Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role).      A minimum standard speed for  optimal  performance is 25mbs  download  x 10 mbs upload  is  required .      Check your internet speed at   www.speedtest.net      A dedicated office space lacking ongoing interruptions so you can meet productivity requirements, and  to protect  member PHI / HIPAA information.     Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid