Provider Dispute Utilization Management Nurse Central Region

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

Creating Healthy Communities is good for the Soul. Join Us! The Provider Dispute Utilization Management Nurse 2 utilizes their clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for providers and members.

Review UM post claim inpatient admission and clinical information from a provider disputed claim for appropriate level of care

Collaborate with Humana departments and regional UM teams

Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas

Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed

Follows established guidelines/procedures

Required Qualifications

Licensed Registered Nurse (RN) Compact State Licensure and/or Illinois or Minnesota License with no disciplinary action

3-5 years of prior clinical experience preferably in an acute care hospital, skilled or rehabilitation clinical setting

Utilization Management experience is required for this role

CGX experience is required

Milliman MCG experience

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Excellent communication skills both verbal and written

Ability to work independently under general instructions and with a team

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

Previous Provider Dispute experience highly preferred

Bachelor's degree in nursing (BSN)

Health Plan experience

Previous Medicare experience a plus

CRM experience

Working knowledge of claims review process

Work-At-Home Requirements

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

Satellite, cellular and microwave connection can be used only if approved by leadership

Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense

Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job

Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information

Hours are: Monday-Friday 7am-4pm or 8am-5pm CST, there is some flexibility with schedules

Preference is for the candidate to reside within states located in this region, but will consider candidates that live in other states also

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