PRN Utilization Review 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
Healthcare, InsuranceIndustries
Requirements
- Licensed Registered Nurse (RN) in the appropriate state with no disciplinary action
- 3 or more years of clinical experience, preferably in an acute care, skilled or rehabilitation clinical setting or broad clinical nursing experience
- Comprehensive knowledge of Microsoft Word, Outlook and Excel
- Strong organizational and effective time management skills
- Ability to work independently under general instructions and with a team
- Ability to meet work-at-home requirements (e.g., minimum internet speeds of 25 Mbps download/10 Mbps upload, dedicated workspace protecting PHI/HIPAA)
- Availability for Monday-Friday 9am-6pm EST with weekend rotation and holidays as needed
- Residence in Eastern Standard Time Zone (EST)
Responsibilities
- Assist in preparation of cases prior to review by Humana G&A Medicare Medical Directors
- Review medical documentation, research claims, benefits, and prior determinations pertinent to the appeal
- Provide a written summary of findings using a template for each case
- Collaborate with Humana CIT teams, Vendors, G&A specialists, and Humana Medical Directors on submitted G&A cases
- Participate in initiatives to improve member outcomes, operational efficiencies, and process improvement opportunities
- Prepare cases for Medicare and/or Duals line of business involving expedited, pre-service and post-service appeals
- Apply and implement Medicare, Medicaid, MCG, claims policy and evidence of coverage guidelines for reviews
- Perform outreach to providers and/or members
- Utilize multiple systems such as MHK, CGX, MRM, SRO
Skills
Key technologies and capabilities for this role
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