Remote Manager Registered Nurse, RN, UM, Clinical Claims Review

Humana

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Location: OK
Location Type: Remote
Schedule:Full_time
Req: R-323054

Description

 

The Manager, Utilization Management Nursing-CCR utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. The Manager, Utilization Management Nursing works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules, and goals. This professional is also responsible to review and document compliance within any Medicaid state contract requirement and NCQA guideline for all direct reports.

 

Responsibilities

 

The Manager, Utilization Management Nursing uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for members.

Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

 

               

Required Qualifications

  • Active Licensed Registered Nurse (RN) holding a compact license with no disciplinary action
  • 2+ years of management/leadership, project lead or subject matter expert experience
  • 2+ years of Utilization Management experience.
  • 2+ years Progressive clinical experience
  • Intermediate to Advanced proficiency using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment.
  • Ability to work independently under general instructions and with a team

 

Workstyle: Remote work at home

Location:  Oklahoma

Schedule: Monday-Friday 8:30 AM – 5:00 PM Central Time with possible rotating on-call coverage and oversight during weekends and holidays.

Travel: Minimal travel for office meetings 1-2 times annually as business needs.

 

Preferred Qualifications

  • Bachelor’s Degree
  • Prior supervisory or staff management experience
  • Managed Care / Health Plan experience
  • Prior Medicaid experience
  • Call center or triage experience
  • Bilingual is a plus

Work-At-Home Requirements

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

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor.  This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. (Please be sure to check your spam or junk folders often to ensure communication isn’t missed) If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided.  Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

 

SSN Alert

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.

 

Benefits

Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security—both today and in the future, including:
Health benefits effective day 1; Paid time off, holidays, volunteer time and jury duty pay; Recognition pay; 401(k) retirement savings plan with employer match
Tuition assistance; Scholarships for eligible dependents; Parental and caregiver leave; Employee charity matching program; Network Resource Groups (NRGs)
Career development opportunities

 

#L1-Remote

 

Scheduled Weekly Hours

 

40