Humana Telephonic Utilization Management Nurse (RN) - Work at home - Texas in San Antonio, Texas

Role: Telephonic Utilization Management Nurse (RN)

Assignment: Medicare

Location: Work at home - Texas

Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana’s Perfect Service® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.

Assignment Capsule

Be a part of our Clinical Space – as a Clinical Advisor you will engage our members to develop lifelong wellbeing and health.

Humana is seeking a Utilization Management Nurse who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.

This is a work at home position with the preferred candidate living within the state of Texas. The ideal candidate will also have at least 5 years of varied clinical experience, some utilization management and/or case management experience, be computer proficient in Word, Excel and Outlook, and exude our core nursing values of being positive, dedicated and loyal in your profession.

Responsibilities include:

  • 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

Role Essentials

  • Active RN license in the state(s) in which the nurse is required to practice

  • Ability to be licensed in multiple states without restrictions

  • At least 5 years prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting

  • Ability to work independently under general instructions and with a team

  • Computer proficient with Microsoft Office products; Word, Excel and Outlook

  • Valid drivers 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

Role Desirables

  • Education: BSN or Bachelor’s degree in a related field

  • Health Plan experience

  • Previous Medicare/Medicaid Experience a plus

  • Call center or triage experience

  • Previous experience in utilization management, case management, discharge planning and/or home health or rehab

  • Bilingual is a plus

Additional Information

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.

Interview Format

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 (please be sure to check your spam or junk folders often to ensure communication isn’t missed) 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.

Title: Telephonic Utilization Management Nurse (RN) - Work at home - Texas

Location: Texas-San Antonio

Requisition ID: 178542

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.