Telephonic Utilization Management Nurse – Daytona Beach, FL
Some responsibilities include:
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.
Be a part of our Clinical Space – as a Clinical Advisor you will engage our members to develop lifelong wellbeing and health.
Humana is seeking a telephonic UR nurse 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
Active RN license in the state(s) in which the nurse is required to practice
Ability to be licensed in multiple states without restrictions
Previous experience in utilization management, discharge planning and/or home health or rehab
Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
Proficient with Microsoft Office including Word, Outlook and Excel
Ability to work independently under general instructions and with a team
Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home’s systems if 10Mx1M
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