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
- 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.
- 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
- 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
You will report to a Manager or Supervisor. This area is under the leadership of the SVP & Chief Operating Officer.
Clinical Innovations and Health Practitioners
Work Environment Type
Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...