Company name
Humana Inc.
Location
Springfield, MO, United States
Employment Type
Full-Time
Industry
Healthcare, Nursing
Posted on
Apr 18, 2023
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