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 the state(s) in which the nurse is required to practice
Ability to be licensed in multiple states without restrictions
3 years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
Ability to work independently under general instructions and with a team
BSN or Bachelors degree in a related field
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Previous experience in Home Health
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 Front Line Leader.
Clinical Innovations and Health Practitioners
Work Environment Type
Yes, 10 % of the Time
Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...