Risk Management Professional 2 (Licensed Nurse Required)

Become a part of our caring community The Risk Management Professional 2 is responsible for leading and executing quality audits within the CenterWell Utilization Management (UM) program, ensuring compliance with regulatory requirements, including CMS and NCQA standards. This role is heavily focused on audit accuracy, data analysis, and identification of risks and trends, with an emphasis on leveraging Power BI and Power Apps to support audit processes, reporting, and performance monitoring. The successful candidate will bring deep expertise in clinical criteria and regulatory guidance (e.g., Medicare Manuals, NCDs, LCDs, coverage policies, MCG) and demonstrate a strong passion for quality and continuous improvement. This role requires the ability to translate audit findings into meaningful insights, identify root causes, and support program audit readiness from a clinical and research-based perspective. An active, unrestricted Registered Nurse (RN).Key ResponsibilitiesConduct comprehensive quality audits of UM activities to ensure adherence to regulatory standards (CMS, NCQA) and organizational policiesEvaluate clinical decision-making and appropriate application of criteria across inpatient, outpatient, home health, and post-acute servicesLeverage Power BI to develop, maintain, and interpret dashboards reporting audit outcomes, performance trends, and risk areasUtilize Power Apps to support audit workflows, tracking, and data collection processesAnalyze audit results to identify risks, trends, and patterns, and clearly communicate findings to leadershipPerform root cause analysis to determine drivers of opportunities, inconsistencies, and compliance gapsDemonstrate strong familiarity with clinical criteria sources, including:Medicare ManualsNational Coverage Determinations (NCDs)Local Coverage Determinations (LCDs)Plan coverage policiesMCG guidelinesSupport program audits (CMS, NCQA) by contributing clinical insight, validating documentation, and ensuring audit readiness from a regulatory and research-based perspectiveCollaborate with clinical, operational, and compliance teams to drive quality improvement initiatives based on audit findingsDemonstrate a high level of attention to detail and a strong commitment to quality and accuracyTranslate complex data into actionable insights and recommendations for stakeholdersPresent audit findings, risks, and trend analyses confidently to leadership and cross-functional teams Use your skills to make an impact Required QualificationsActive, unrestricted Registered Nurse (RN)Extensive experience in utilization management, clinical auditing, and/or quality assuranceStrong knowledge of CMS, NCQA, and regulatory/accreditation requirementsDeep understanding of clinical criteria and coverage guidelines (Medicare manuals, NCDs, LCDs, MCG, etc.)Demonstrated experience identifying audit risks, trends, and root causesExperience supporting or participating in regulatory program audits (CMS, NCQA)Strong analytical and critical thinking skills with ability to interpret and act on dataExceptional attention to detail and commitment to quality outcomesAbility to communicate complex findings clearly and influence stakeholdersPreferred QualificationsPrior experience in a dedicated auditor or quality oversight roleExperience working in healthcare environments across inpatient, outpatient, home health, and post-acute careFamiliarity with audit tracking tools, reporting systems, and dashboardsExperience translating data into reporting and insightsWork at Home RequirementsTo ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours40Pay RangeThe compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$65,000 - $88,600 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-bei