You will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.
Examine clinical programs information to identify members for specific Case Management/Chronic Care / or Disease Management activities or interventions by utilizing established screening criteria
Provider education on referral management and processes
Monitor practice's patient participation in Humana's clinical programs.
Promote Humana's clinical programs and resources
Facilitate member clinical program engagement
Identifies areas to engage member clinical program participation.
Consult with Clinical Program Case Mangers and nurses to identify member specific opportunities to address with a Provider
Identify Chronic Complex members not participating in Humana Cares and refer PODS members to program
Expertise on Clinical Programs available to PODS members, and ability to analyze available data to identify members who can benefit from available programs.
Consult with PODS owner on Clinical Program opportunities needing addressed in a Provider visit
Review member specific and provider specific data to identify concerns needing follow up by assigned Case Managers
Identify medication usage opportunities needing Pharmacy Consultant involvement.
Coordination of Clinical Program specific representation or input in to PODS Owner or Strategy Meetings
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 the state(s) in which the nurse is required to practice
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 with a team
Valid driver’s license and/or dependable transportation necessary (variable by region))
Strong analytical skills, able to manipulate and interpret data
Coding knowledge and experience
Office practice/ hospital experience
Organizational and prioritization skills
Education: Bachelors or Associates degree in Nursing
Health Plan experience
Previous Medicare/Medicaid Experience a plus
CMS Stars/performance measures/HEDIS
knowledge and experience
Call center or triage experience
knowledge and experience
Provider and member rewards program knowledge and experience
Experience in a state and/or federally regulated health care environment
Understanding of clinical programs
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
Yes, 20 % of the Time
Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...