Utilization Management amp Medical Coding Registered Nurse RN

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 for Humana's Kentucky Medicaid Plan. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Utilization Management Nurse 2 uses 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 members. Manages clinical claim reviews and disputed claims. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. 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) in the state of Kentucky with no disciplinary action and ability to hold licenses in multiple states without restriction.
2 years variety progressive clinical experience in heart, lung, critical care, acute care, skilled or rehabilitation setting
1 year minimum experience working as a Utilization Management Nurse, preferably using MCG
Medical Coding Certification and/or 3 years equivalent work experience
Intermediate/Advanced working knowledge with MS Office Suite to include Word, Excel, Power Point,
2 years Technical experience aptitude to troubleshoot and resolve system platform and connectivity problems
Experience with the development and implementation of policies and procedures
Ability to work independently under general instructions and with a team


Additional Requirements/Adherence


Work Style: Remote Work at Home
Location: Kentucky, Louisville preferred
Alternate Locations: Will consider other locations
Hours: Typically an 8 hours shift Monday-Friday between 8:00 AM and 5:00 PM Eastern Time with rotating on-call coverage and oversight during weekends and holidays.
Travel: Travel up to 5% may be required as this role is an agile workstyle with a combination telephonic in an office and may anticipate visiting onsite facilities depending on the supported region.
Work at Home Requirement: To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
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


Preferred Qualifications


Bachelor's Degree
In-hospital Utilization Management experience
MCG experience
1 year Care Management experience in an acute care, skilled or Rehabilitation clinical setting
Certified Case Manager, CCM
Health Plan experience
Medicaid experience
Bilingual is a plus - Language Proficiency Assessment will be performed to test fluency in reading, writing and speaking in both languages before placing on a dedicate line to service our members.


Additional Information

Humana Covid:


Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.


Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

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 ****

Company info

Sign Up Now - NursingCrossing.com