Humana RN Telephonic Acute Utilization Review - FL in Lancaster, South Carolina
Role: RN Utilization Review
Assignment:Medicare - Front End Review
Location:work at home role eastern time zone - focus on members in FL
Must be able to work eastern time zone hours of Mon-Fri, 8am-5pm EST.
Humana is seeking a Utilization Review RN who will completing medical necessity reviews of inpatient admissions of Medicare members,
C ollaborate 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
Active RN license without restrictions
Ability to be licensed in multiple states without restrictions
1-2 years experience in an adult acute care setting
At least 6 months hospital utilization management using Interqual or MCG
Excellent computer skills, specifically MS Excel & Word and ability to easily navigagte multiple applications
Strong communication and organization skills
Ability to work independently in a dynamic environment
Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); recommended speed is 10Mx1M
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Bilingual is a plus
As part of our hiring process for this opportunity, we will be using a technology called Montage Voice which allows us to quickly connect and gain valuable information from you about your relevant experience.
If you are selected for a phone screen you will receive an email inviting you to participate in a Montage Voice interview. During this call you will be asked a set of questions pertaining to this particular role and you will provide recorded responses. The entire process takes about 15-20 minutes and can be done at your convenience. Your responses will be reviewed and you will be informed if you were selected for an in person or video interview, depending on your location.
Title: RN Telephonic Acute Utilization Review - FL
Other Locations: US-North Carolina-Charlotte, US-FL-Plantation, US-FL-Tampa, US-South Carolina-Lancaster
Requisition ID: 189557
Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.