RN Utilization Management, Behavioral Health

About the position

The RN Utilization Management, Behavioral Health position at Humana involves utilizing behavioral health knowledge to support the coordination, documentation, and communication of medical services. This role is primarily remote, allowing for flexibility while ensuring that the nurse is located and licensed in a Compact State. The position requires completing medical record reviews, assessing discharge plans, and collaborating with an interdisciplinary team to ensure quality care and compliance with performance standards.

Responsibilities
• Complete medical record reviews from Behavioral Health Facilities to obtain sufficient clinical information.
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• Assess discharge plans for patients.
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• Review and extract information from claims related to behavioral health services.
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• Complete documentation for Quality Reviews and Peer Reviews.
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• Discuss cases with Medical Directors to ensure appropriate care.
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• Work in partnership with other members of the Humana Interdisciplinary team.
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• Comply with performance and reporting standards as defined by Humana.
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• Complete additional responsibilities as deemed appropriate by Humana leadership.

Requirements
• Minimum of Associate Degree in Nursing.
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• Registered Nurse (R.N.) licensure with no disciplinary action.
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• Registered nurse with Compact Licensure (licensed and located in compact state).
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• Minimum of three (3) years of post-degree clinical experience in direct patient care with adult population.
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• Experience in a Behavioral Health setting is required.
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• Proficiency with Microsoft Office products: Outlook, Word & Excel.
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• Adept at working via a computer on multiple screens and platforms, and comfortable learning new programs.
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• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice-to-haves
• Bachelor's or advanced degree in nursing.
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• Experience in Behavioral Health, Utilization Management, and/or Behavioral Health utilization management experience (performing medical necessity reviews against criteria such as MCG, ASAM, Interqual, etc.).
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• Experience using EMR systems.
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• Additional Non-compact nursing licenses.
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• Bilingual (English/Spanish); speaking, reading, writing, interpreting and explaining documents in Spanish.

Benefits
• Competitive benefits package including health insurance and wellness programs.
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• Early access to pay.
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• Professional growth opportunities.

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