Role:RN Acute Utilization Management
Location:Work at Home in eastern time zone
The hours for this role are Mon-Fri, 8am-5pm est.
Humana is seeking a Utilization Review RN to r eview clinical information to ensure appropriateness of services, utilizing Milliman and CMS guidelines.
Interact with providers utilizing effective collaboration to insure safe discharge,
collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.
Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using your knowledge of benefit plan design
Recommend services for Humana Plan members utilizing care alternatives available within the community and nationally
Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols
Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions by utilizing established screening criteria
Conduct admission review, post-discharge calls and discharge planning
Active RN license in the state(s) in which the nurse is required to practice
Ability to be licensed in multiple states without restrictions
Previous experience in utilization management, case management, discharge planning and/or home health or rehab strongly preferred.
Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
Proficient with Microsoft Office Word, Outlook and Excel
Ability to work independently under general instructions and with a team
Valid driver’s license and/or dependable transportation necessary (variable by region)
Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 10Mx1M
Education: BSN or Bachelor’s degree in a related field
Health Plan experience
Call center or triage experience
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
If you are selected for a first round interview, you will receive an email correspondence inviting you to participate in a Montage Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.
Title: RN Acute Utilization Management – Eastern Time Zone
Other Locations: US-South Carolina-Lancaster
Requisition ID: 182252
Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.