UM BH Registered Nurse
About The Position
This internship program is designed for transitioning military service members or military spouses seeking to gain experience in the healthcare field. The DOW SkillBridge Internship and Military Spouse Fellowship Programs provide key training to support members, projects, and business goals. Professionals at Humana may include healthcare professionals, HR, and IT. The objective is to support and facilitate care for members. To be eligible, candidates must be a transitioning military service member or a military spouse and obtain eligibility for the DOW sponsored programs. The Utilization Management Behavioral Health Registered Nurse (RN) Intern will report to a manager of the National Medicaid team. They will use training and acquired skillsets to complete medical necessity reviews for behavioral health requested services, using clinical judgment and providing referrals as needed. Networking opportunities will be provided. Full-time employment is not guaranteed upon completion.
Requirements
- Must be a transitioning service member eligible to participate in the DOW SkillBridge or a military spouse eligible to participate in the military spouse fellowship.
- Active Registered Nurse, RN, in the state of Kentucky or an enhanced Compact, (eNLC) license without restrictions or disciplinary action.
- Minimum two (2) years of clinical behavioral health experience.
- Working knowledge of MS Office including Word, Excel, PowerPoint, and Teams in a Windows based environment.
- Ability to quickly learn new systems.
- Ability to troubleshoot and resolve basic technical difficulties in a remote environment.
- Proficiency in healthcare software and electronic medical records (EMR) systems.
- Possess an interest in working in the managed care industry.
Nice To Haves
- Bachelor's degree
- Previous Medicare/Medicaid experience.
- Previous experience in prior authorization, utilization management.
- Experience working with MCG or Interqual guidelines.
- Certification in Case Management, (CCM) or Utilization Review, (UR).
- Knowledge of payer policies, insurance companies and government health programs.
Responsibilities
- Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility.
- Apply advanced evidence-based clinical guidelines in review decisions.
- Ensure compliance with accreditation, state, and federal regulations.
- Communicate with healthcare providers to obtain necessary clinical information and clarify requests.
- Coordinate with medical directors and interdisciplinary teams to support decision-making.
- Serve as a liaison between clinicians, internal departments, and members.
- Document all review findings and decisions in clinical documentation systems.
- Ensure timely and accurate documentation of prior authorization determinations.
- Support reporting initiatives and provide data for performance improvement projects.
- Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions.
- Conduct regular audits and reviews to maintain high standards of service.
- Identify process improvement opportunities and contribute to performance improvement projects.
- Educate providers and staff on prior authorization policies, criteria, and review processes.
- Provide mentorship and feedback to nonclinical staff and peers to enhance workflow efficiency.
- Stay current with clinical best practices and regulatory changes.
Benefits
- Networking opportunities
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What This Job Offers
Career Level
Entry Level
Education Level
Associate degree
