UM BH Registered Nurse

Humana•Oklahoma City, ND

1d•Remote

About The Position

Become a part of our caring community Are you a transitioning military service member or a military spouse looking for an internship that supports the goal to put health first? The DOW SkillBridge Internship and Military Spouse Fellowship Programs will provide you with key training to perform your internship. You will partner with your team to support members, projects, and to meet goals impacting business outcomes. The professionals you work with at Humana will depend on the type of internship you select. They may include healthcare professionals, HR, and IT, to name a few. The objective is to support and facilitate care for members. To be eligible for this internship, you must either be a transitioning military service member or a military spouse, and you must obtain eligibility to participate in these DOW sponsored programs. The Utilization Management Behavioral Health Registered Nurse (RN) Intern will report to a manager of the National Medicaid team. You will utilize training and engage formerly acquired skillsets to complete medical necessity reviews for behavioral health requested services using clinical judgment and provides referrals to internal stakeholders for further review depending on case findings. You will participate in the following assignments in this role: Clinical Review: 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. Communication and Coordination: 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. Documentation and Reporting: 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. Quality Assurance: 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. Education and Training: 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. Use your skills to make an impact

Requirements

You 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 and an ability to quickly learn new systems and 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.
Must have the ability to provide a high-speed DSL or cable modem for a home office.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

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.