Utilization Management Appeals Nurse

Become a part of our caring community and help us put health first

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Humana is seeking a Part C Grievance & Appeals (G&A) Nurse who will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews 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. The associate will be working and collaborating with Humana CIT teams, Vendors, G&A specialists, and Humana Medical Directors on submitted G&A cases.

The G&A Nurse will participate in initiatives which result in improved member outcomes, operational efficiencies, and process improvement opportunities.

• 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

• Licensed Registered Nurse (RN) 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

• Strong organizational and effective time management skills

• Ability to work independently under general instructions and with a team

• Bachelor’s degree (BSN)

• Appeal Review Experience

• Knowledge of MHK

• Previous Medicare/Medicaid Experience

• Previous experience in utilization management

• Previous claims experience

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

• Hours are Monday-Friday 9am-6pm EST with a weekend rotation (Your 8-hour shift will fall within this timeframe)

• Candidate’s must also commit to working on the holidays as needed

• This is a remote position, but all candidates must work in the Eastern Standard Time Zone (EST)

Travel:
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$71,100 - $97,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family…