Utilization Management Nurse - Front End Review

Florida, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must reside in Florida and possess a Bachelor's degree or higher, along with a Licensed Registered Nurse (RN) license in Florida without disciplinary action. A minimum of 3-5 years of experience in Medical Surgery, Heart, Lung, or Critical Care Nursing is required, as is comprehensive knowledge of Microsoft Word, Outlook, and Excel. Prior clinical experience, preferably in an acute care setting, and the ability to work independently under general instructions and with a team are also necessary.

Responsibilities

The Utilization Management Nurse 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, coordinating with providers and members, and making independent decisions regarding work methods. The nurse will also monitor and interpret changes in employment legislation and develop HR policies to ensure compliance.

Skills

Utilization Management

Clinical Nursing

Medical-Surgical Nursing

Heart Care Nursing

Lung Care Nursing

Critical Care Nursing

Microsoft Word

Microsoft Outlook

Microsoft Excel

MCG Guideline

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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