RN Utilization Front End Review - Richmond, VA

Company Name:
## Description
Role: RN Front End Review
Assignment: Medicare
Location: Richmond, VA
Humana's dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana's Perfect Service means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.
Assignment Capsule
Be a part of our Clinical Space - as a Clinical Advisor you will engage our members to develop lifelong wellbeing and health.
Humana is seeking a Clinical RN Advisor who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.
Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using your knowledge of benefit plan design
Recommend services for Humana Plan members utilizing care alternatives available within the community and nationally
Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols
Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions by utilizing established screening criteria
Conduct admission review, post-discharge calls and discharge planning
Key Competencies
_Builds Trust_ : Consistently models and inspires high levels of integrity, lives up to commitments, and takes responsibility for the impact of one''s actions.
_Accountability_ : Meets established expectations and takes responsibility for achieving results; encourages others to do the same.
_Customer Focus_ : Connects meaningfully with customers to build emotional engagement and customer advocacy. Simplifies complexity and integrates internal efforts to deliver an optimal customer experience.
_Executes for Results:_ Effectively leverages resources to create exceptional outcomes, embraces change, and constructively resolves barriers and constraints.
## Qualifications
Role Essentials
Active RN license
Ability to be licensed in multiple states without restrictions
Prior clinical experience in an acute care setting
Strong computer proficiency
Critical thinking and effective communication skills
Ability to work independently under general instructions and with a team
Role Desirables
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Call center or triage experience
Previous experience in utilization management
Additional Information
Humana is an organization with careers that change lives--including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you're ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.
Apply now, or join our Talent Network so you can stay informed and up to date on what's happening at Humana.
Schedule: Full-time
Primary Location: US-Virginia-Glen Allen
Role: Service Operations
Travel: Yes, 5 % of the Time
Req ID: 125463
Work Environment Type: Virtual/Work At Home

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