Humana Inc., headquartered in Louisville, Kentucky, is one of the nation's largest publicly traded health benefits companies. Humana offers a diversified portfolio of health insurance products and related services - through traditional and consumer-choice plans - to employer groups, government-sponsored plans, and individuals.
Today, Humana is a leader in consumer engagement. Throughout its diversified customer portfolio, the company provides guidance that can both help lower costs and lead to a better health plan experience.
Role: Service Operations Clinical Advisor-RN
Assignment: Medical Review
Location: Louisville, KY - Waterside
Are you a fit?
Are you an analytical thinker and a self-starter? Would you enjoy using your medical knowledge to evaluate claims from Humana’s customers and partners?
Assignment Capsule
As a medical review clinical advisor you will: research, evaluate and recommend appropriate health solutions, providing accurate and effective information to satisfy the medical concerns, questions and issues of Humana’s customers and partners.
Provide support for the Claims Adjusting and Customer Service areas of the service center by performing retrospective claim reviews and reconsiderations
Research new procedures and products, appropriate drug use, and both claims and contracts to help determine appropriate coverage levels
Prepare medical necessity reviews for the Regional Medical Director, external review organizations or peer reviewers with thoroughness, accuracy and effectiveness
Key Competencies
Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.
Leveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
Implementation/Execution: You are good at organizing and managing multiple priorities and/or projects by using appropriate methodologies and tools.
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.
Role Essentials
Registered Nurse (RN)
Minimum 3 years experience as an RN
Experience in transplants or triage
Role Desirables
Comprehensive knowledge of Microsoft Word and Excel
Strong written and verbal communication skills
Reporting Relationships
You will report to a Frontline Leader. This area is under the leadership of the SVP & Chief Operating Officer.
Humana - 2 years ago
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