RN Utilization Review Nurse
Humana - Metairie, LA

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You will 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
Key Competencies
  • Leveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
  • Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.
  • Is Accountable: You meet clearly stated expectations and take responsibility for achieving results.
  • Clinical Knowledge: You understand clinical program design, implementation, management/monitoring to support choice in consumer medical care. Understands the medical utilization implications of such programs
  • Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.

Role Essentials
  • Active RN license in LA.
  • Ability to be licensed in multiple states without restrictions
  • Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
  • Ability to work independently under general instructions and with a team
Role Desirables
  • Education: BSN or Bachelors degree in a related field
  • Health Plan experience
  • Previous Medicare/Medicaid Experience a plus
  • Call center or triage experience
  • Previous experience in utilization management, discharge planning and/or home health or rehab
  • Bilingual is a plus
Reporting Relationships

You will report to a Manager or Supervisor. This area is under the leadership of the SVP & Chief Operating Officer.

Additional Information

: Full-time

Primary Location : US-Louisiana-Metairie

Role : Clinical Innovations and Health Practitioners

Work Environment Type : Office

Humana - 16 months ago - save job - copy to clipboard - block
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About this company
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Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...