Care Manager – Telephonic Nurse Assistant
Humana
Registered Nurse, Compliance
Humana
full-time
Posted on:
Location Type: Remote
Location: Remote • California, Illinois, Kentucky, Louisiana, Montana, Ohio, Oklahoma, South Dakota, Wisconsin • 🇺🇸 United States
Visit company websiteSalary
💰 $71,100 - $97,800 per year
Job Level
Mid-LevelSenior
About the role
- Review utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse
- Ensure mandatory reporting completed
- Conduct and summarize compliance audits
- Collect and analyze data to assess outcome and operational metrics for the team and individuals
- Review denial letters issued to members and providers to ensure compliance with accreditation entities and State contractual requirements
- Follow established guidelines/procedures
- Make decisions regarding own work methods and require minimal direction, receiving guidance where needed
- Work remotely and occasionally travel to Humana offices for training or meetings
Requirements
- Active Registered Nurse license in a state that is part of the Enhanced Nursing Licensure Compact (eNLC) compact without disciplinary action
- Ability to obtain additional state licensures without restrictions
- A minimum of three years varied clinical nursing experience
- 2 years of experience in utilization management with MCG Guidelines
- Ability to work independently under general instructions and with a team
- Intermediate or better proficiency using Microsoft Office Word, Excel, PowerPoint
- Ability to navigate multiple systems and platforms and troubleshoot basic technical difficulties in a remote environment
- BSN (preferred)
- Behavioral Health Utilization Management (preferred)
- Health Plan experience working with large carriers (preferred)
- Previous Medicare/Medicaid experience (a plus)
- Experience with National Committee for Quality Assurance (NCQA) requirements (preferred)
- Must reside in a state that is part of the Enhanced Nursing Licensure Compact (eNLC)
- Must be able to work an 8-hour shift Monday through Friday with end of shift time of 6:00 PM Eastern Time
- Ability to work weekends and holidays on a rotating schedule (about 1 weekend day per month, and 2 holidays per year)
- Minimum internet requirements: download 25 Mbps and upload 10 Mbps; wireless, wired cable or DSL connection required; Satellite, cellular and microwave allowed only if approved by leadership
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Benefits
- 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
- Bi-weekly internet payment for associates in CA, IL, MT, SD (if living and working from home)
- Telephone equipment provided
- Occasional travel to Humana's offices for training or meetings
ATS Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
utilization managementclinical nursing experienceMCG Guidelinesdata analysiscompliance auditsMicrosoft Office WordMicrosoft Office ExcelMicrosoft Office PowerPointMedicare experienceMedicaid experience
Soft skills
independent workteam collaborationdecision makingminimal directioncommunicationorganizational skillsproblem solvingadaptabilityattention to detailtime management
Certifications
Registered Nurse licenseBSN
