Utilization Management Nurse 2-Remote US

Profile

Description

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

Humana is seeking a Part C Grievance & Appeals (G&A) Nurse will be working and collaborating with Humana CIT teams, Vendors, G&A specialists, and Humana Medical Directors on submitted G&A cases. The G&A Nurse will participate in initiatives which result in improved member outcomes, operational efficiencies, and process improvement opportunities.

Case preparation of Medicare and/or Duals line of business involving expedited, pre-service and post service appeals

Apply and implement Medicare, Medicaid, MCG, claims policy and evidence of coverage guidelines for reviews

Perform outreach to providers and/or members

Utilize multiple systems such as MHK, CGX, MRM, SRO.

Required Qualifications

Associate's Degree

Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action

3 or more years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting or broad clinical nursing experience

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Ability to work independently under general instructions and with a team

Work-At-Home Requirements

WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

Education: BSN or Bachelor's degree in a related field

Appeal Review Experience

Knowledge of MHK

Previous Medicare/Medicaid Experience

Previous experience in utilization management

Previous claims experience

Additional Information

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana's secure website.

Vaccination Policy

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Scheduled Weekly Hours

40

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 https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Company info

Humana Inc.
Website : http://www.humana.com