Humana

Utilization Management Nurse - Home Solutions - Compact RN Required

Kentucky, United States

Not SpecifiedCompensation
Mid-level (3 to 4 years)Experience Level
Full TimeJob Type
UnknownVisa
Health Insurance, HealthcareIndustries

Requirements

Candidates must possess a minimum of an Associate Degree in nursing and hold a current, valid Licensed Registered Nurse (RN) license in a compact state with no disciplinary actions. They must also have a compact license or reside in a compact state and be eligible to upgrade to compact licensure. A minimum of three years of progressive and varied clinical experience, including direct patient care to the geriatric population, is required, along with effective telephonic and virtual communication skills and comprehensive knowledge of Microsoft Word, Outlook, and Excel. The ability to work independently under general instructions and within a team is also necessary. Preferred qualifications include a Bachelor’s degree and two or more years of home health or utilization management experience, as well as experience in a managed care or health plan setting. For remote work, a high-speed DSL or cable modem (minimum 25mbs download/10mbs upload) and a dedicated, interruption-free office space are mandatory.

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 coordinating and communicating with providers, members, and other parties to facilitate optimal member care and treatment, ensuring fully coordinated care at home. Responsibilities include interpreting clinical information to make recommendations for improving patient outcomes, navigating multiple systems and screens while working cases, and collaborating effectively with internal and external parties. The nurse will also make decisions regarding their own work methods, occasionally in ambiguous situations with minimal direction, and follow established guidelines, processes, and procedures.

Skills

Utilization Management
Telephonic Communication
Clinical Nursing
Coordination
Documentation
Benefit Administration
Medical Services
Critical Thinking
Organizational Skills
Time Management
Analytical Skills
Patient Outcomes
Collaboration

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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