UM Behavioral Health Nurse

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Candidates must possess a Licensed Registered Nurse (RN) Compact license with no disciplinary actions and have at least 3 years of clinical experience in an acute care setting. Proficiency in Microsoft applications such as Word, Outlook, and Excel is required, along with comfort in learning new computer programs. A Bachelor's degree in nursing (BSN), experience in Behavioral Health and/or Utilization Management, familiarity with MCG or InterQual, and managed care experience are preferred. Additional non-compact nursing licenses and bilingual skills are a plus. For remote work, a minimum internet download speed of 25 Mbps and upload speed of 10 Mbps via wireless, wired cable, or DSL is recommended, with specific exceptions for certain states.

Responsibilities

The Utilization Management Behavioral Health Nurse will utilize clinical nursing skills to coordinate, document, and communicate behavioral health services and benefit administration determinations. This role involves completing medical record reviews from behavioral health facilities, assessing discharge plans, reviewing and extracting information from claims, and completing documentation for Quality Reviews and Peer Reviews. The nurse will also discuss cases with Medical Directors, partner with the Humana Interdisciplinary team, and comply with performance and reporting standards. Additional responsibilities may be assigned by leadership. The work hours are based on business needs between 7:00 AM and 6:30 PM CST, Monday through Friday, and occasional travel for training or meetings may be required.

Skills

Licensed Registered Nurse (RN)

Clinical Nursing Skills

Medical Record Review

Discharge Planning

Claims Review

Quality Review

Peer Review

Microsoft Word

Microsoft Outlook

Microsoft Excel

EMR

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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