JOB DESCRIPTION AND DETAILS
Role: Telephonic Utilization Review Nurse (RN)
Location: Torrance, CA – Work at Home
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.
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 Telephonic Utilization Review Nurse who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria. This is considered a work at home opportunity with in office training. The UM Nurse will also be conducting oversight of members belonging to Independent Physician Associations (IPA) UM inpatient functions by communicating with the IPA UM staff regarding members with long lengths of stay. Also, the UM Nurse will be making outreach calls to members to conduct ER Surveys and/or a post discharge care coordination survey with purpose of closing any gaps identified.
- 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, discharge planning post-discharge calls to members.
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