Utilization Management Nurse Reviewer
Blank StreetFull Time
Mid-level (3 to 4 years), Senior (5 to 8 years)
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.
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.
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.