Quality Assurance Professional

Become a part of our caring community The Quality Assurance Professional reviews Long-Term Services and Support (LTSS) contractor documentation and performance to ensure compliance with contract scope of work, and state and federal regulations. You will ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse to ensure appropriate course of action. You will understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Your work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Comply, conduct, and summarize compliance audits/reports to include deficiencies and risks. Collect, review records, summarize issues and analyze data daily, weekly, monthly, or as needed to assess outcome and operational metrics for the team and individuals. Conduct inter-rater reliability audits for multiple vendor activities such as Home- and Community-Based Services (HCBS) service calculators and nursing facility level of care determination assessments to ensure accurate and consistent application of state and Humana guidelines. Ensure Michigan Department of Health and Human Services (MDHHS), National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and Humana Gold-Plus Integrated Policy and Procedures are followed. Ensure auditing is completed timely and communicat