Be a part of our Clinical Space – as a Clinical Advisor you will engage our members to develop lifelong wellbeing and health
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
: Consistently models and inspires high levels of integrity, lives up to commitments, and takes responsibility for the impact of one's actions.
: Meets established expectations and takes responsibility for achieving results; encourages others to do the same.
: Connects meaningfully with customers to build emotional engagement and customer advocacy. Simplifies complexity and integrates internal efforts to deliver an optimal customer experience.
Executes for Results:
Effectively leverages resources to create exceptional outcomes, embraces change, and constructively resolves barriers and constraints.
Active RN license
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
Strong analytical skills, able to manipulate and interpret data
Coding knowledge and experience
Office practice/ hospital experience
Organizational and prioritization skills
This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
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
Utilization management 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.
At Humana, we know your well-being is important to you, and it’s important to us too. That’s why we’re committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. If you share our passion for helping people, we likely have the right place for you at Humana.
After applying, we encourage you to join our Talent Network as well, so you can stay informed and up to date on what’s happening around our organization in the changing world of healthcare.
Clinical Innovations and Health Practitioners
Work Environment Type
Office, Virtual/Work At Home
Yes, 50 % of the Time
Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...