DescriptionThe Telephonic UM Nurse utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Telephonic UM Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Role: Telephonic UM Nurse, RN
Location: Work at Home, Texas residence preferred
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 Experience 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 Utilization Management 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.
Preferred applicants will live in the state of Texas with a minimum of three years nursing experience; have a background in utilization management including knowledge of MCG or Interqual guidelines and experience with large health plans. Clinical background in LTAC, Inpatient Rehab and SNF a plus. Strong attention to detail is required for this role, along with, efficient computer skills with a proficiency in Word, Excel and Outlook.
- 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
- Strong attention to detail
- A minimum of three years varied nursing experience
- Proficient with MS Office products including Word, Excel and Outlook
- Ability to work independently under general instructions and with a team
- Valid drivers license and/or dependable transportation necessary (variable by region)
- 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 for Humana systems is 10Mx1M
- Ability to provide a designated workspace; free from distractions with the ability to secure any protected information.
- Texas residency preferred
- Education: BSN or Bachelor’s degree in a related field
- Health Plan experience working with large carriers
- Previous Medicare/Medicaid experience a plus
- Prior work in LTAC, Inpatient Rehab and Skilled Nursing Facilities a plus
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab
- Certification in Case Management a plus (CCM)
- Experience working with MCG or Interqual guidelines
Scheduled Weekly Hours40