Utilization Review Clinician
WellSkyFull Time
Mid-level (3 to 4 years)
Candidates must possess a Licensed Registered Nurse (RN) in an enhanced compact (eNLC) with no disciplinary action. A minimum of one year of experience in Behavioral Health Nursing, which includes inpatient, outpatient, psychiatric, or substance use settings, is required. Comprehensive knowledge of Microsoft Word, Outlook, and Excel is necessary, along with the ability to work independently under general instructions and as part of a team. Previous experience in utilization management, knowledge of ASAM, health plan experience, and previous Medicare/Medicaid experience are preferred. Bilingual skills are a plus. Candidates must reside in a state participating in the enhanced nurse licensure (ENLC).
The Utilization Management Nurse 2 will utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. This role involves interpreting criteria, policies, and procedures to provide optimal care and services for members, using clinical knowledge, communication skills, and independent critical thinking. Responsibilities include coordinating and communicating with providers, members, and other parties to facilitate optimal care and treatment, and making decisions regarding work methods with minimal direction.
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.