Humana is seeking a Clinical RN Advisor who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines 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
Conduct admission review, post-discharge calls and discharge planning
Active RN license in the state of Florida
Ability to be licensed in multiple states without restrictions
Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
Ability to work independently under general instructions and with a team
Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home’s systems if 10Mx1M
This role will include weekend shifts and working both 8 and 10 hour shifts.
Education: BSN or Bachelor’s degree in a related field
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Call center or triage experience
Previous experience in utilization management, discharge planning and/or home health or rehab
Bilingual is a plus
Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.
Clinical Innovations and Health Practitioners
Work Environment Type
Office, Virtual/Work At Home
Yes, 5 % of the Time