Utilization-Management-Nurse, Registered-Nurse, Clinical-Review-Nurse Jobs

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Humana Healthy Horizons is more than a health plan. We're human care. Humana Healthy Horizons focuses on helping people achieve their best health. Our dedicated strategies across various markets and states are enabled by partnerships with state and local governments, community-based organizations, and national partners committed to removing barriers to helping people achieve their best health.
The Utilization Management (UM) Nurse uses clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. The Utilization Management Nurse 2's work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Position Responsibilities:

• Use clinical knowledge toward interpreting criteria and procedures to provide the best and most appropriate treatment, care, or services for Enrollees
• Coordinate and Communicate with Providers, Enrollees or other parties to facilitate optimal care and treatment
• Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas
• Use judgment regarding own work methods, occasionally in ambiguous situation, and receiving guidance where needed
• Follow established guidelines and procedures
• Periodic travel to Humana Oklahoma City office for meetings and training

Use your skills to make an impact

Required Qualifications:

• Must Reside in Oklahoma
• An active Licensed Registered Nurse (RN), unrestricted
• 3+ years of prior clinical experience, preferably in an acute care, skilled or rehabilitation clinical setting
• Comprehensive knowledge of Microsoft Excel and Outlook
• Ability to work a weekend rotation

Preferred Qualifications:

• Previous experience in Utilization Management
• Prior experience with EPIC Programs
• Previous remote work experience

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$71,100 - $97,800 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Originally posted on Himalayas

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Job Summary

Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and/or other contracted lines of business. This role assesses and evaluates the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.

Requirements

EDUCATION

• Bachelor's degree in Nursing preferred.

LICENSING/CERTIFICATION

• Registered Nurse (RN) with active, current, unrestricted and recognized in the relevant jurisdiction, state license in good standing in the state(s) where job duties are performed required.

EXPERIENCE

• Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.
• Experience in utilization management and/or medical review preferred.

ESSENTIAL SKILS & ABILITIES

• Oral & Written Communication
• Attention to Detail
• Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding.
• Ability to prioritize and make sound nursing judgments through critical thinking.
• Ability to build collaborative relationships.
• Ability to interpret complex documentation.
• Ability to work independently.
  

LOCATION

Work from home within Arkansas, Washington, Oregon, Utah, Idaho, North Dakota, or Minnesota. Preference will be given to current employees and candidates who reside in Arkansas, Utah, Idaho, and North Dakota.

Skills

• Active Listening• Analytical Decision Making• Critical Thinking• Data Analysis• Educational Development• Interpersonal Relationship Management• Microsoft Outlook• Microsoft SharePoint• Microsoft Word• Oral Communications• Problem Sensitivity• Sound Judgment• Team Development• Time Management• Written Communication

Responsibilities

• Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.• Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards.• Performs other duties as assigned.• Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.• Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.• Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.• Works incoming and outbound calls and/or queues from multiple sources within mandated requirements proactively and effectively.

Certifications

Hiring Range

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.

Originally posted on Himalayas