Utilization Management Nurse

Humana

4d • $71,100 - $97,800 • Remote

About The Position

The Part C Grievance & Appeals (G&A) Nurse (Utilization Management Nurse 2) utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. Your work assignments will be varied and frequently require interpretation and independent determination of the appropriate courses of action. Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. You will review the medical documentation, researching claims, benefits, as well as prior determinations pertinent to the appeal and provides a written summary of findings using a template for each case. You will work and collaborate with Humana CIT teams, Vendors, G&A specialists, and Humana Medical Directors on submitted G&A cases. You will participate in initiatives which result in improved member outcomes, operational efficiencies, and process improvement opportunities.

Requirements

• Associate's Degree
• Licensed Registered Nurse (RN) with compact license in the (appropriate state) with no disciplinary action
• 3 or more years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting or broad clinical nursing experience
• Comprehensive knowledge of Microsoft Word, Outlook and Excel
• Ability to work independently under general instructions and with a team
• Self-provided internet service must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice To Haves

• BSN or Bachelor's degree in a related field
• Appeal Review Experience
• Knowledge of MHK
• Medicare/Medicaid Experience
• Experience in utilization management
• Claims experience
• Leadership experience

Responsibilities

• Case preparation of Medicare and/or Duals line of business involving expedited, pre-service and post service appeals
• Apply and implement Medicare, Medicaid, MCG, claims policy and evidence of coverage guidelines for reviews
• Perform outreach to providers and/or members
• Utilize multiple systems such as MHK, CGX, MRM, SRO
• Overseeing weekend workflow, monitoring appeal inventory, prioritizing case assignments, and helping ensure timely and accurate processing in alignment with operational and compliance expectations.
• Serve as a resource for associates, provide real-time guidance, identify inventory risks and workload gaps, and escalate issues as needed.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree