Humana Utilization Registered Nurse - Telephonic - Daytona FL or reside within the North Florida Region in Tampa, Florida

Role: RN - Utilization Review, WAH Assignment: Monday-Friday - flexibility to work weekends as part of 40 hr. shift Location: Daytona FL or reside within the North Florida Region,

Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana’s Perfect Service® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.

Assignment Capsule Be a part of our Clinical Space – as a Utilization Review RN you will engage our members to develop lifelong wellbeing and health.

Humana is seeking a Utilization Review RN who 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

    Role Essentials

  • Active unrestricted RN license in the state of Florida and ability to be licensed in multiple states without restrictions

  • Ability to work an 8 hour shift, 5 days and flexibility to work weekends

  • Reside within reasonable distance to Daytona, FL or within the Northern Florida Region

  • Prior clinical experience in an acute care, skilled or rehabilitation clinical setting

  • Ability to work independently under general instructions and with a team

  • Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work

  • Must have accessibility to hardwired high speed internet with minimum speeds of 10Mx1M for a home office (Wireless and Satellite are prohibited)

  • Intermediate to advanced computer skills and experience with Microsoft Word, Excel and Outlook

    Additional Requirements if role requires field visits, patient facing: o Possession of a valid driver's license and access to an automobile

    o This role is considered patient facing and is a part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

    o AHCA Fingerprint Required

    Role Desirables

  • 3 years prior clinical experience in an acute care, skilled or rehabilitation clinical setting

  • 3 years previous experience in utilization management, discharge planning

  • 1 year minimum hospital case management and/or hospital discharge planning

  • Working knowledge using Milliman or Interqual experience

  • Education: BSN or Bachelor’s degree in a related field

  • Health Plan experience

  • Previous Medicare/Medicaid Experience a plus

  • Call center or triage experience

  • Bilingual is a plus Additional Information

    Interview Format As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

    If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn’t missed) inviting you to participate in a Montage Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

    Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.

    Apply now, or join our Talent Network so you can stay informed and up to date on what’s happening at Humana.

Title: Utilization Registered Nurse - Telephonic - Daytona FL or reside within the North Florida Region

Location: FL-Tampa

Other Locations: US-FL-Daytona Beach, US-FL-Pensacola, US-FL-Jacksonville

Requisition ID: 190920

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.