Location: Metairie, LA
Location Type: Metairie – Remote
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.
- 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.
- Must reside in Louisiana’s Medicaid Regions 1 – 9.
- 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.
- Experience in driving provider level quality improvement initiatives and outcomes to achieve quality targets.
- Strong understanding of quality improvement culture, behavioral change models.
- 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…..
- 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)
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.
Scheduled Weekly Hours
Search by License
Search Jobs by State
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Carolina
- South Dakota
- West Virginia