[Remote] UM Behavioral Health Nurse at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Licensed Registered Nurse (RN) Compact license, with no disciplinary action
3 or more years of clinical experience
Proficient in Microsoft applications including Word, Outlook, Excel
Adept experience working with computers and comfortable learning new programs
Self-provided internet service meeting minimum speeds (25 Mbps download, 10 Mbps upload recommended; wireless, wired cable or DSL suggested; satellite/cellular/microwave only if approved)
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Availability Monday – Friday from 6:00 AM-6:00 PM EST, based on business need (40 scheduled weekly hours)

Responsibilities

Utilize clinical nursing skills to support coordination, documentation, and communication of medical services and/or benefit administration determinations
Use clinical knowledge, communication skills, and independent critical thinking to interpret criteria, policies, and procedures for appropriate treatment, care, or services
Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment
Complete medical record reviews for Behavioral Health Inpatient and Outpatient Provider Disputes
Cross train in Physical Health Provider Disputes based on business need
Review and extract information from claims
Work in partnership with other members of the Humana Interdisciplinary team
Comply with performance and reporting standards as defined by Humana
Complete additional responsibilities as deemed appropriate by Humana leadership
Understand department, segment, and organizational strategy and operating objectives, including linkages to related areas
Make decisions regarding own work methods, occasionally in ambiguous situations, with minimal direction

Skills

Key technologies and capabilities for this role

Registered Nurse (RN)Compact licenseUtilization ManagementBehavioral HealthMedical Record ReviewClaims ReviewMicrosoft OfficeClinical NursingCritical Thinking

Questions & Answers

Common questions about this position

What qualifications are required for the UM Behavioral Health Nurse position?

Candidates must be a Licensed Registered Nurse (RN) with a compact license and no disciplinary action, have 3 or more years of clinical experience, and be proficient in Microsoft applications including Word, Outlook, and Excel.

Is this a remote position, and what are the work-at-home requirements?

The role supports work-at-home or hybrid home/office arrangements, requiring self-provided internet with at minimum a download speed of 25 Mbps and upload speed of 10 Mbps; wireless, wired cable or DSL is suggested, with satellite, cellular, or microwave needing leadership approval.

What are the working hours for this role?

The department operates Monday through Friday from 6:00 AM to 6:00 PM EST, with hours for this role based on business need within that timeframe.

What preferred qualifications will strengthen my application?

Preferred qualifications include a Bachelor’s degree in nursing (BSN), Behavioral Health and/or Utilization Management experience, acute care clinical setting experience, MCG or InterQual experience, managed care experience with insurance companies, and additional non-compact nursing licenses.

What is the salary or compensation for this position?

This information is not specified in the job description.

Humana

Health insurance provider for seniors and military

About Humana

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.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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