Humana Nurse Auditor, Utilization Management Denials - Doral, FL in Miami, Florida
The Compliance/Audit Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The hours of this role are Mon-Fri, 8am-5pm est. The work location will be the office in Doral. FL for the first 6 months and will then transition to a full time work at home. Occasional overtime as needed based on the needs of the business.
The Compliance/Audit Nurse 2 ensures mandatory reporting completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
RN or LPN with active license in FL
Ability to be licensed in multiple states without restrictions
Prior clinical experience in an acute care, skilled or rehabilitation clinical setting
Experience in utilization management
Excellent computer skills and ability to easily navigate multiple applications
Strong communication skills, both verbal and written
Ability to work independently under general instructions and with a team
BSN or Bachelor's degree in a related field
Health Plan experience working with large carriers
Previous experience as a UM Auditor
Experience working with MCG guidelines
Strong preference for bilingual (able to read and write in Spanish)
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.
Scheduled Weekly Hours
Mission: At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.
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