Utilization Review Clinician - RN - Remote
WellSkyFull Time
Senior (5 to 8 years)
Candidates must be a licensed Registered Nurse (RN) with no disciplinary action and possess a Compact License. A minimum of one year of clinical experience in an RN role within an acute care setting, preferably in specialty areas like critical care or emergency room, is required, along with comprehensive knowledge of Microsoft Word, Outlook, and Excel. The ability to work independently under general instructions and as part of a team is essential, as is a passion for improving consumer experiences. Preferred qualifications include a BSN or Bachelor's degree in a related field, three or more years of acute care clinical experience, experience as an MDS Coordinator or discharge planner, previous utilization management/review experience, a single state RN licensure in California, Hawaii, Nevada, or Oregon in addition to a Compact license, health plan experience, Medicare/Medicaid experience, call center or triage experience, and bilingual skills.
The Utilization Management Nurse 2 will utilize clinical nursing skills to coordinate, document, and communicate medical services and benefit administration determinations. This role involves interpreting criteria, policies, and procedures to ensure members receive the most appropriate treatment, care, or services, and requires independent decision-making with minimal direction. Responsibilities include coordinating and communicating with providers, members, and other parties to facilitate optimal care and treatment, understanding department and organizational strategy, and making decisions regarding work methods, sometimes in ambiguous situations. The role also requires adherence to established guidelines and procedures.
Health insurance provider for seniors and military
Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.