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 Responsibilities Conduct comprehensive quality audits of UM activities to ensure adherence to regulatory standards (CMS, NCQA) and organizational policies Evaluate clinical decision-making and appropriate application of criteria across inpatient, outpatient, home health, and post-acute services Leverage Power BI to develop, maintain, and interpret dashboards reporting audit outcomes, performance trends, and risk areas Utilize Power Apps to support audit workflows, tracking, and data collection processes Analyze audit results to identify risks, trends, and patterns, and clearly communicate findings to leadership Perform root cause analysis to determine drivers of opportunities, inconsistencies, and compliance gaps Demonstrate strong familiarity with clinical criteria sources, including: Medicare Manuals National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) Plan coverage policies MCG guidelines Support program audits (CMS, NCQA) by contributing clinical insight, validating documentation, and ensuring audit readiness from a regulatory and research-based perspective Collaborate with clinical, operational, and compliance teams to drive quality improvement initiatives based on audit findings Demonstrate a high level of attention to detail and a strong commitment to quality and accuracy Translate complex data into actionable insights and recommendations for stakeholders Present audit findings, risks, and trend analyses confidently to leadership and cross-functional teams Use your skills to make an impact Required Qualifications Active, unrestricted Registered Nurse (RN) Extensive experience in utilization management, clinical auditing, and/or quality assurance Strong knowledge of CMS, NCQA, and regulatory/accreditation requirements Deep understanding of clinical criteria and coverage guidelines (Medicare manuals, NCDs, LCDs, MCG, etc.) Demonstrated experience identifying audit risks, trends, and root causes Experience supporting or participating in regulatory program audits (CMS, NCQA) Strong analytical and critical thinking skills with ability to interpret and act on data Exceptional attention to detail and commitment to quality outcomes Ability to communicate complex findings clearly and influence stakeholders Preferred Qualifications Prior experience in a dedicated auditor or quality oversight role Experience working in healthcare environments across inpatient, outpatient, home health, and post-acute care Familiarity with audit tracking tools, reporting systems, and dashboards Experience translating data into reporting and insights 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 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 Hours 40 Pay Range The 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 year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 09-25-2026 About us About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being. About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.