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.

Assignment Capsule

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

Role Essentials

  • 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

Role Desirables

  • Health Plan experience

  • Previous Medicare/Medicaid Experience a plus

  • Bilingual is a plus

Additional Information

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

Location: FL-Miramar

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.