Humana Inc., headquartered in Louisville, Kentucky, is one of the nation\'s largest publicly traded health benefits companies. Humana offers a diversified portfolio of health insurance products and related services - through traditional and consumer-choice plans - to employer groups, government-sponsored plans, and individuals.
Today, Humana is a leader in consumer engagement. Throughout its diversified customer portfolio, the company provides guidance that can both help lower costs and lead to a better health plan experience.
Role:
Clinical Innovations / Clinical Advisor, RN/LVN
Assignment:RN/LVN Precert Nurse
Location: San Antonio, TX
Are you a fit
Do you enjoy working with medical members\' Do you have a desire to be in a position where you can \'provide guidance to our member population as it is related to their health care needs\' If so then read on!
Assignment Capsule
You will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines and Milliman review criteria.
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
Key Competencies
Leveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.
Is Accountable: You meet clearly stated expectations and take responsibility for achieving results.
Clinical Knowledge: You understand clinical program design, implementation, management/monitoring to support choice in consumer medical care. Understands the medical utilization implications of such programs
Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.
Role Essentials
Active RN/LVN license in the state(s) in which the nurse is required to practice
Ability to be licensed in multiple states without restrictions
Minimum of 5 years clinical experience in an acute care setting
Ability to work independently under general instructions and with a team
Role Desirables
BSN or Bachelors degree in a related field
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Call center or triage experience
Previous experience in utilization management or discharge planning
Bilingual is a plus
Reporting Relationships
You will report to a Manager or Supervisor. This area is under the leadership of the SVP & Chief Operating Officer.
Additional Information
See AboveJob type: Full TimeEducation: BachelorExperience: 3-5 Years
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