UM BH Registered Nurse
Humana, Phila, PA, United States
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 provide referrals to internal stakeholders for further review depending on case findings.
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.
Required Qualifications
Transitioning service member or military spouse eligible to participate in the DOW SkillBridge or 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 ability to quickly learn new systems and troubleshoot basic technical difficulties in a remote environment.
Proficiency in healthcare software and electronic medical records (EMR) systems.
Interest in working in the managed care industry.
Preferred Qualifications
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.
Workstyle:
Remote Work at Home
Location:
Must reside in a state that participates in the enhanced compact license (eNLC)
Work Schedule:
Weekdays 8:00 AM to 4:30 PM Central Time
Travel:
None; occasional travel to Humana's offices for training or meetings may be required.
Work At Home Requirements:
Must have a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
Minimum standard speed for optimal performance of 25 Mbps download × 10 Mbps upload is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space with no ongoing interruptions to protect member PHI/HIPAA information.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
#J-18808-Ljbffr
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 provide referrals to internal stakeholders for further review depending on case findings.
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.
Required Qualifications
Transitioning service member or military spouse eligible to participate in the DOW SkillBridge or 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 ability to quickly learn new systems and troubleshoot basic technical difficulties in a remote environment.
Proficiency in healthcare software and electronic medical records (EMR) systems.
Interest in working in the managed care industry.
Preferred Qualifications
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.
Workstyle:
Remote Work at Home
Location:
Must reside in a state that participates in the enhanced compact license (eNLC)
Work Schedule:
Weekdays 8:00 AM to 4:30 PM Central Time
Travel:
None; occasional travel to Humana's offices for training or meetings may be required.
Work At Home Requirements:
Must have a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
Minimum standard speed for optimal performance of 25 Mbps download × 10 Mbps upload is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space with no ongoing interruptions to protect member PHI/HIPAA information.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
#J-18808-Ljbffr