RN, Utilization Management (Clinical Claims Review)
New
H
HumanaHealthcare
US Nationwide, Monday through Friday, 8:00 AM – 5:00 PMFull-TimeMiddle
Salary$71,100 - $97,800 per year
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Job Details
- Languages
- Bilingual proficiency in Spanish and English
- Experience
- 3+ years of experience in prior authorization, claims review, utilization management, or other healthcare/health insurance environments; 3+ years of nursing experience in one or more of the following areas: Medical-Surgical, Cardiac, Pulmonary, Maternity/Obstetrics, or Critical Care.
- Required Skills
- Microsoft Excel
Requirements
- Licensed Registered Nurse (RN) in an Enhanced Nurse Licensure Compact (eNLC) state, with no disciplinary actions.
- Ability to obtain and maintain multiple state Registered Nurse (RN) licenses.
- 3+ years of experience in prior authorization, claims review, utilization management, or other healthcare/health insurance environments.
- 3+ years of nursing experience in Medical-Surgical, Cardiac, Pulmonary, Maternity/Obstetrics, or Critical Care.
- Prior clinical experience in acute care, skilled nursing, rehabilitation, or similar healthcare setting.
- Intermediate to advanced proficiency in Microsoft Office applications (Word, Outlook, Excel).
- Ability to navigate multiple systems and platforms.
- Must have a dedicated workspace with high-speed internet (min 25 Mbps download/10 Mbps upload).
- Bachelor's degree in Nursing (BSN) or related field is preferred.
- Previous experience working for a health plan, managed care organization, or health insurance provider is preferred.
- Bilingual proficiency in Spanish and English is preferred.
Responsibilities
- Support the coordination, documentation, and communication of medical services or benefit administration determinations.
- Interpret criteria and procedures to facilitate appropriate treatment and care for members.
- Coordinate and communicate with providers, members, and other parties to facilitate care.
- Understand department, segment, and organizational strategy and operating goals.
- Follow established guidelines and procedures to ensure consistent decision-making.
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