Utilization Management Nurse Reviewer
Blank StreetSalary not specified
Full Time
Mid-level (3 to 4 years), Senior (5 to 8 years)
Not SpecifiedCompensation
Mid-level (3 to 4 years)Experience Level
Full TimeJob Type
UnknownVisa
Health Insurance, HealthcareIndustries
Requirements
Candidates must possess an active Licensed Practical Nurse (LPN) or Licensed Registered Nurse (RN) license in Florida with no disciplinary actions. A minimum of one year of experience in Long Term Supports and Services (LTSS) and prior utilization management experience are required. Proficiency in Microsoft Word, Outlook, and Excel is also necessary. A Bachelor's degree, previous Medicare/Medicaid experience, case management experience, CGX experience, and MCG certification are preferred qualifications.
Responsibilities
The Utilization Management Nurse 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 and care within Humana’s Florida LTSS program. Responsibilities include coordinating and communicating with providers, members, and other parties to facilitate optimal care, making independent decisions regarding work methods, and following established guidelines.
Skills
Licensed Practical Nurse (LPN)
Licensed Registered Nurse (RN)
Utilization Management
Microsoft Word
Microsoft Outlook
Microsoft Excel
Medicare
Medicaid
Case Management
MCG certification
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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