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 Management 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.
Preferred applicants will live in the state of Texas with a minimum of three years nursing experience; have a background in utilization management including knowledge of MCG or Interqual guidelines and experience with large health plans. Strong computer skills are a necessary with proficiency in Word, Excel and Outlook.
- 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
- Active RN license in the state(s) in which the nurse is required to practice
- Ability to be licensed in multiple states without restrictions
- A minimum of three years varied nursing experience
- Proficient with MS Office products including Word, Excel and Outlook
- Ability to work independently under general instructions and with a team
- Valid drivers license and/or dependable transportation necessary (variable by region)
- Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance for Humana systems is 10Mx1M
- Ability to provide a designated workspace; free from distractions with the ability to secure any protected information.
- Texas residency preferred
- Education: BSN or Bachelor’s degree in a related field
- Health Plan experience working with large carriers
- Previous Medicare/Medicaid experience a plus
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab
- Certification in Case Management a plus (CCM)
- Experience working with MCG or Interqual guidelines
- Bilingual English/Spanish a plus. Ability to speak, read and write in both languages without limitations or assistance. See Additional Information on testing
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.
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn’t missed)
inviting you to participate in a Montage Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Language Proficiency Testing
Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.
Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.