UM BH Registered Nurse

You will utilize training and engage formerly acquired skillsets to complete medical necessity reviews for behavioral health requested services using clinical judgment and provides referrals to internal stakeholders for further review depending on case findings. You will participate in the following assignments in this role: 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 Use your skills to make an impact * You must be a transitioning service member eligible to participate in the DOW SkillBridge or a military spouse eligible to participate in the 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 an ability to quickly learn new systems and ability to troubleshoot and resolve basic technical difficulties in a remote environment. * Proficiency in healthcare software and electronic medical records (EMR) systems. * Possess an 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 Additional Information Work At Home Requirements * WAH requirements: Must have the ability to provide 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. * A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required. * Satellite and Wireless Internet service is NOT allowed for this role. * A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information The DOW SkillBridge Internship Program provides transitioning military service members time to gain civilian work experience while still on active duty with an employer for a period approved by their command and the DOW, with an average timeline of 90 days. The Military Spouse Fellowship Program connects military spouses with employers offering a variety of professional onsite, field, or remote based opportunities for a period up to 12 weeks. * Networking opportunities will be provided while participating in the Internship or Fellowship. * Due to factors such as location, and/or requirements that cannot be modified, full-time employment is not guaranteed upon completion of the Internship or Fellowship. Interview Format As part of our hiring process, we will be using a screening and interviewing technology provided by HireVue, a third-party vendor. This technology provides our team of recruiters and hiring leaders with 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) 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. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 1 About Us About Humana: Humana Inc. (NYSE: HUM) is a leading U. S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. 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 to 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.