Risk Management Professional, Licensed Nurse

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CenterWell Senior Primary Care

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

Healthcare Insurance

CenterWell Senior Primary Care is a healthcare provider focused on delivering personalized primary care to senior citizens. The company emphasizes a comprehensive and holistic approach to healthcare, addressing the physical, social, and emotional needs of older adults. As part of its service offerings, CenterWell includes home health services and pharmacy support to complement its senior primary care. The organization is committed to offering stability, inclusive benefits, and career growth opportunities for its employees while maintaining a culture of mutual respect and mindfulness. CenterWell is a brand under the larger healthcare entity, Humana.

📋 Description

• 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 • Collaborate with clinical, operational, and compliance teams to drive quality improvement initiatives based on audit findings

🎯 Requirements

• 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.

🏖️ Benefits

• 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