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) is required. 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, and 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 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 Employees must provide their own internet service meeting a minimum download speed of 25 Mbps and an upload speed of 10 Mbps, with wireless, wired cable or DSL connection suggested. In certain roles the minimum recommended internet speed may need to be upgraded by the company. A dedicated space that minimizes interruptions is required to protect member PHI / HIPAA information. Occasional travel to company offices for training or meetings may be required. Job Details Scheduled weekly hours: 40 hours Pay range: $65,000 - $88,600 per year This position is eligible for a bonus incentive plan based on company and/or individual performance. Benefits Humana, Inc. and its affiliated subsidiaries offer competitive benefits that support whole‑person well‑being. Benefits include medical, dental and vision coverage, a 401(k) retirement savings plan, paid time off (including holidays, paid parental and caregiver leave), short‑term and long‑term disability, life insurance, and additional opportunities. 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. CenterWell, a wholly owned subsidiary of 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 full accessibility rights information and language options at #J-18808-Ljbffr Humana Inc