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Nurse jobs at Humana
- 167 jobsNurse Auditor 2
Humana
Nurse job at Humana
**Become a part of our caring community and help us put health first** The Nurse Auditor 2 performs clinical audit/validation processes to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant and accurate to support optimal reimbursement. The Nurse Auditor 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Nurse Auditor 2 validates and interprets medical documentation to ensure capture of all relevant coding. Applies clinical and coding experience to conduct a clinical validation review of the inpatient medical record to validate billed diagnoses. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. **Use your skills to make an impact** **WORK STYLE:** Remote/Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **WORK HOURS:** Typical business hours are Monday-Friday, 8 hours/day, 5 days/week. Associates are expected to start each day between 6AM and 9AM in their home time zone. **Required Qualifications** + Active Registered Nurse (RN) license in the state they reside. + Minimum of 2 consecutive years acute inpatient hospital care experience in critical, intensive care setting within the last 5 years (Not pediatrics or neonatal). For example: ICU, CCU, PCU, med-surg/adult units or a minimum of 2 years DRG Inpatient auditing. NOTE: Inpatient experience does **not** refer to any other levels of care such as ER, OR, Pre-op, PACU,L&D, mother-baby, behavioral health, SNF, care manager/discharge manager, LTC, rehab, outpatient or office/clinic visits such as wound care, oncology, radiology, interventional radiology, lab, hospice, or home health. + In depth knowledge and critical understanding of complex medical diagnoses including, but not limited to, Sepsis (including end-organ failure), Pneumonia, Acidosis, Renal Failure, Encephalopathy, CVA, DKA, MI, etc. + Advanced knowledge of MS Office (Word, Excel, etc) + Excellent writing, editing, interpersonal, planning, teamwork, and communications skills + Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information + Ability to work independently and manage workload + Customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession **Preferred Qualifications** + Bachelor's Degree in relevant field preferred + Inpatient coding certification (AHIMA or AAPC - ex: RHIA, RHIT, CCS, CIS, CIC) + Inpatient coding claim experience + Prospective payment methodologies, DRG auditing experience + Clinical documentation improvement knowledge (CDE, CDEI certification) **Additional Information** **Work at Home Requirements** - 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 for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue (formerly Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. 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 or computer 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. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $78,400 - $107,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. **About us** Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large. **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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************$78.4k-107.8k yearly 60d+ agoLVN Delegation Oversight Nurse Remote
Molina Healthcare
Columbus, OH jobs
The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. This position will support our Corporate Compliance business. The candidate must have an unrestricted LVN licensure. Candidates must be technologically proficient, self-directed, autonomous and experience working from home. Care Management & Waiver Service Auditing experience is highly preferred. Work hours: Monday - Friday 8:00am - 4:00pm Remote position Essential Job Duties Coordinates, conducts and documents pre-delegation and annual assessments as necessary to comply with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements. Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed. Works with delegation oversight analytics representatives on monitoring performance reports from delegated entities. Develops corrective action plans (CAPs) when deficiencies are identified, and documents follow-up to completion. Assists with delegation oversight committee meetings. Works with delegation oversight leadership to develop and maintain delegation assessment tools, policies and reporting templates. Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. Participates as needed in joint operation committees (JOCs) for delegated groups. Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed. Required Qualifications At least 3 years' experience in health care, including 2 years' experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience. Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). The license must be active and unrestricted in state of practice. Knowledge of audit processes and applicable state and federal regulations. Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines. Ability to collaborate effectively with team members and internal departments. Strong attention to detail with a focus on maintaining quality in all tasks. Strong verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $77,969 - $128,519 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$78k-128.5k yearly 2d agoLVN Delegation Oversight Nurse Remote
Molina Healthcare
Cleveland, OH jobs
The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. This position will support our Corporate Compliance business. The candidate must have an unrestricted LVN licensure. Candidates must be technologically proficient, self-directed, autonomous and experience working from home. Care Management & Waiver Service Auditing experience is highly preferred. Work hours: Monday - Friday 8:00am - 4:00pm Remote position Essential Job Duties Coordinates, conducts and documents pre-delegation and annual assessments as necessary to comply with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements. Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed. Works with delegation oversight analytics representatives on monitoring performance reports from delegated entities. Develops corrective action plans (CAPs) when deficiencies are identified, and documents follow-up to completion. Assists with delegation oversight committee meetings. Works with delegation oversight leadership to develop and maintain delegation assessment tools, policies and reporting templates. Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. Participates as needed in joint operation committees (JOCs) for delegated groups. Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed. Required Qualifications At least 3 years' experience in health care, including 2 years' experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience. Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). The license must be active and unrestricted in state of practice. Knowledge of audit processes and applicable state and federal regulations. Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines. Ability to collaborate effectively with team members and internal departments. Strong attention to detail with a focus on maintaining quality in all tasks. Strong verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $77,969 - $128,519 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$78k-128.5k yearly 2d agoLVN Delegation Oversight Nurse Remote
Molina Healthcare
Toledo, OH jobs
The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. This position will support our Corporate Compliance business. The candidate must have an unrestricted LVN licensure. Candidates must be technologically proficient, self-directed, autonomous and experience working from home. Care Management & Waiver Service Auditing experience is highly preferred. Work hours: Monday - Friday 8:00am - 4:00pm Remote position Essential Job Duties Coordinates, conducts and documents pre-delegation and annual assessments as necessary to comply with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements. Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed. Works with delegation oversight analytics representatives on monitoring performance reports from delegated entities. Develops corrective action plans (CAPs) when deficiencies are identified, and documents follow-up to completion. Assists with delegation oversight committee meetings. Works with delegation oversight leadership to develop and maintain delegation assessment tools, policies and reporting templates. Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. Participates as needed in joint operation committees (JOCs) for delegated groups. Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed. Required Qualifications At least 3 years' experience in health care, including 2 years' experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience. Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). The license must be active and unrestricted in state of practice. Knowledge of audit processes and applicable state and federal regulations. Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines. Ability to collaborate effectively with team members and internal departments. Strong attention to detail with a focus on maintaining quality in all tasks. Strong verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $77,969 - $128,519 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$78k-128.5k yearly 2d agoLVN Delegation Oversight Nurse Remote
Molina Healthcare
Akron, OH jobs
The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. This position will support our Corporate Compliance business. The candidate must have an unrestricted LVN licensure. Candidates must be technologically proficient, self-directed, autonomous and experience working from home. Care Management & Waiver Service Auditing experience is highly preferred. Work hours: Monday - Friday 8:00am - 4:00pm Remote position Essential Job Duties Coordinates, conducts and documents pre-delegation and annual assessments as necessary to comply with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements. Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed. Works with delegation oversight analytics representatives on monitoring performance reports from delegated entities. Develops corrective action plans (CAPs) when deficiencies are identified, and documents follow-up to completion. Assists with delegation oversight committee meetings. Works with delegation oversight leadership to develop and maintain delegation assessment tools, policies and reporting templates. Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. Participates as needed in joint operation committees (JOCs) for delegated groups. Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed. Required Qualifications At least 3 years' experience in health care, including 2 years' experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience. Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). The license must be active and unrestricted in state of practice. Knowledge of audit processes and applicable state and federal regulations. Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines. Ability to collaborate effectively with team members and internal departments. Strong attention to detail with a focus on maintaining quality in all tasks. Strong verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $77,969 - $128,519 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$78k-128.5k yearly 2d agoLVN Delegation Oversight Nurse Remote
Molina Healthcare
Cincinnati, OH jobs
The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. This position will support our Corporate Compliance business. The candidate must have an unrestricted LVN licensure. Candidates must be technologically proficient, self-directed, autonomous and experience working from home. Care Management & Waiver Service Auditing experience is highly preferred. Work hours: Monday - Friday 8:00am - 4:00pm Remote position Essential Job Duties Coordinates, conducts and documents pre-delegation and annual assessments as necessary to comply with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements. Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed. Works with delegation oversight analytics representatives on monitoring performance reports from delegated entities. Develops corrective action plans (CAPs) when deficiencies are identified, and documents follow-up to completion. Assists with delegation oversight committee meetings. Works with delegation oversight leadership to develop and maintain delegation assessment tools, policies and reporting templates. Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. Participates as needed in joint operation committees (JOCs) for delegated groups. Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed. Required Qualifications At least 3 years' experience in health care, including 2 years' experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience. Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). The license must be active and unrestricted in state of practice. Knowledge of audit processes and applicable state and federal regulations. Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines. Ability to collaborate effectively with team members and internal departments. Strong attention to detail with a focus on maintaining quality in all tasks. Strong verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $77,969 - $128,519 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$78k-128.5k yearly 2d agoLVN Delegation Oversight Nurse Remote
Molina Healthcare
Dayton, OH jobs
The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. This position will support our Corporate Compliance business. The candidate must have an unrestricted LVN licensure. Candidates must be technologically proficient, self-directed, autonomous and experience working from home. Care Management & Waiver Service Auditing experience is highly preferred. Work hours: Monday - Friday 8:00am - 4:00pm Remote position Essential Job Duties Coordinates, conducts and documents pre-delegation and annual assessments as necessary to comply with state, federal and National Committee for Quality Assurance (NCQA) guidelines, and other applicable requirements. Distributes audit results letters, follow-up letters, audit tools and annual reporting requirement as needed. Works with delegation oversight analytics representatives on monitoring performance reports from delegated entities. Develops corrective action plans (CAPs) when deficiencies are identified, and documents follow-up to completion. Assists with delegation oversight committee meetings. Works with delegation oversight leadership to develop and maintain delegation assessment tools, policies and reporting templates. Assists with preparation of delegation summary reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. Participates as needed in joint operation committees (JOCs) for delegated groups. Assists in preparation of documents for Centers for Medicare and Medicaid Services (CMS), state Medicaid, National Committee for Quality Assurance (NCQA) and/or other regulatory audits as needed. Required Qualifications At least 3 years' experience in health care, including 2 years' experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience. Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). The license must be active and unrestricted in state of practice. Knowledge of audit processes and applicable state and federal regulations. Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines. Ability to collaborate effectively with team members and internal departments. Strong attention to detail with a focus on maintaining quality in all tasks. Strong verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $77,969 - $128,519 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$78k-128.5k yearly 2d agoRegistered Nurse
Molina Healthcare
Columbus, OH jobs
we are seeking a (RN) Registered Nurse who must hold a compact license. , home office with internet connectivity of high speed required Work Schedule Monday to Friday - operation hours 6 AM to 6 PM (Team will work on set schedule) Looking for a RN with experience with appeals, claims review, and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$26.4-61.8 hourly 2d agoTRA RN and Allied specialties Travel and Local Contracts
Tenet Healthcare
Remote
This is a general application which is applicable across all TRA locations and, all RN and Allied Travel and Local contracts. When you receive your offer letter, it will be customized for the specific position you are hired into. With TRA, you will receive greater contract security than with outside agencies while accessing exciting travel and local contracts across the nation. Why Choose TRA? Guaranteed Hours for Travel Contracts Preferred Booking Agreement for Local Contracts Company Matching funds for the 401K Holiday Pay TRA is preferred for all contract assignments within Tenet while receiving the same tenure as Tenet staff. Location: This is a general application link and, you can be hired into any specific position that fits with what location you are looking to be hired into. As mentioned above, your offer letter will be customized and specific for the position you and your Recruiter speak about.$107k-134k yearly est. Auto-Apply 60d+ agoRegistered Nurse
Molina Healthcare
Covington, OH jobs
For this position we are seeking a (RN) Registered Nurse who lives in OHIO and must be licensed for the state of OHIO. This position will support our MMP (Medicaid Medicare Population) with members on Waiver program. This position will have a case load and manage members enrolled in this program. We are looking for Registered Nurses who have experience working with manage care population and/or case management role. Excellent computer skills and diligence are especially important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. This position requires field work doing assessments with members face to face in homes. TRAVEL in the field to do member visits in the surrounding areas will be required: Cincinnati OH - (Mileage is reimbursed) Schedule - Monday thru Friday 800 AM to 5 PM EST (No weekends or Holidays JOB DESCRIPTION Job Summary Provides support for care management/care coordination long-term services and supports specific activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive member assessments within regulated timelines, including in-person home visits as required. • Facilitates comprehensive waiver enrollment and disenrollment processes. • Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care. • Assesses for medical necessity and authorizes all appropriate waiver services. • Evaluates covered benefits and advises appropriately regarding funding sources. • Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns. • Identifies critical incidents and develops prevention plans to assure member health and welfare. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, including at least 1 year experience in care management, managed care, and/or experience in a medical or behavioral health setting, and at least 1 year of experience working with persons with disabilities, chronic conditions, substance abuse disorders, and long-term services and supports (LTSS), or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Ability to operate proactively and demonstrate detail-oriented work. • Demonstrated knowledge of community resources. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations. • Ability to work independently, with minimal supervision and demonstrate self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency. • In some states, must have at least one year of experience working directly with individuals with substance use disorders. Preferred Qualifications • Certified Case Manager (CCM). • Experience working with populations that receive waiver services. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$26.4-51.5 hourly 1d agoRegistered Nurse
Molina Healthcare
Cincinnati, OH jobs
Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. MULTI STATE / COMPACT LICENSURE Individual state licensures which are not part of the compact states are required for: CA, NV, IL, NY and MI WORK SCHEDULE: Tues - Sat shift will rotate with some holidays. Training will be held Mon - Fri To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$26.4-61.8 hourly 2d agoRegistered Nurse
Molina Healthcare
Beavercreek, OH jobs
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Locations: Ohio Central, NW and WC Region: Delaware, Franklin, Madison, Pickaway, Union, Columbus, Clark, Montgomery, Dayton, Toledo, Lucas County Positions: Community Well, and Nursing Facility Care Management. KNOWLEDGE/SKILLS/ABILITIES Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment. Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Conducts face-to-face or home visits as required. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member case load for regular outreach and management. Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members. Facilitates interdisciplinary care team meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. 25- 40% local travel required. RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens RNs conduct medication reconciliation when needed. JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred. Required Experience 1-3 years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education Bachelor's Degree in Nursing Preferred Experience 3-5 years in case management, disease management, managed care or medical or behavioral health settings. Preferred License, Certification, Association Active, unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. #PJHS2 Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$26.4-51.5 hourly 2d agoRegistered Nurse
Molina Healthcare
Canton, OH jobs
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Positions available in NE Ohio: Cuyahoga, Geauga, Lake, Lorain, Medina and Cleveland KNOWLEDGE/SKILLS/ABILITIES Completes face-to-face comprehensive assessments of members per regulated timelines. Facilitates comprehensive waiver enrollment and disenrollment processes. Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Promotes integration of services for members including behavioral health care and long term services and supports, home and community to enhance the continuity of care for Molina members. Assesses for medical necessity and authorize all appropriate waiver services. Evaluates covered benefits and advise appropriately regarding funding source. Conducts face-to-face or home visits as required. Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns. Identifies critical incidents and develops prevention plans to assure member's health and welfare. Provides consultation, recommendations and education as appropriate to non-RN case managers Works cases with members who have complex medical conditions and medication regimens Conducts medication reconciliation when needed. 50-75% travel required. JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing Required Experience At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports. 1-3 years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association Active, unrestricted State Registered Nursing license (RN) in good standing If field work is required, Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education Bachelor's Degree in Nursing Preferred Experience 3-5 years in case management, disease management, managed care or medical or behavioral health settings. 1 year experience working with population who receive waiver services. Preferred License, Certification, Association Active and unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. #PJHS3 Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$26.4-51.5 hourly 2d agoRegistered Nurse
Molina Healthcare
Akron, OH jobs
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Positions available in NE Ohio: Cuyahoga, Geauga, Lake, Lorain, Medina and Cleveland KNOWLEDGE/SKILLS/ABILITIES Completes face-to-face comprehensive assessments of members per regulated timelines. Facilitates comprehensive waiver enrollment and disenrollment processes. Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Promotes integration of services for members including behavioral health care and long term services and supports, home and community to enhance the continuity of care for Molina members. Assesses for medical necessity and authorize all appropriate waiver services. Evaluates covered benefits and advise appropriately regarding funding source. Conducts face-to-face or home visits as required. Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns. Identifies critical incidents and develops prevention plans to assure member's health and welfare. Provides consultation, recommendations and education as appropriate to non-RN case managers Works cases with members who have complex medical conditions and medication regimens Conducts medication reconciliation when needed. 50-75% travel required. JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing Required Experience At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports. 1-3 years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association Active, unrestricted State Registered Nursing license (RN) in good standing If field work is required, Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education Bachelor's Degree in Nursing Preferred Experience 3-5 years in case management, disease management, managed care or medical or behavioral health settings. 1 year experience working with population who receive waiver services. Preferred License, Certification, Association Active and unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. #PJHS3 Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$26.4-51.5 hourly 2d agoRegistered Nurse
Molina Healthcare
Cleveland, OH jobs
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Locations: Ohio Central, NW and WC Region: Delaware, Franklin, Madison, Pickaway, Union, Columbus, Clark, Montgomery, Dayton, Toledo, Lucas County Positions: Community Well, and Nursing Facility Care Management. KNOWLEDGE/SKILLS/ABILITIES Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment. Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Conducts face-to-face or home visits as required. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member case load for regular outreach and management. Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members. Facilitates interdisciplinary care team meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. 25- 40% local travel required. RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens RNs conduct medication reconciliation when needed. JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred. Required Experience 1-3 years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education Bachelor's Degree in Nursing Preferred Experience 3-5 years in case management, disease management, managed care or medical or behavioral health settings. Preferred License, Certification, Association Active, unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. #PJHS2 Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.$26.4-51.5 hourly 2d agoLead Clinical Review Nurse - Correspondence
Centene
Remote
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Location: Position is remote. Prefer candidate to live in PST time zone. Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST. Position Purpose: Oversees correspondence letters based and supports overall team needs. Reviews outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Oversees the clinical review of outcomes including creating and editing correspondence letters with the correspondence team based on determinations in accordance with National Committee for Quality Assurance (NCQA) standards Manages the audits of correspondence to ensure they are processed in accordance with Federal, State, and NCQA standards Provides expert insight and guidance on the clinical review process of correspondence to ensure compliance with all applicable State and Federal regulations Provides subject matter expertise insights to investigate and resolve issues including comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and escalates as appropriate to resolve issues in a timely manner Acts as a point of contact for escalated, advanced issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer and providers to ensure issues are resolved in a timely manner Oversees clinical quality and process improvement initiatives related to clinical quality indicators and financial metrics Manages data needed to identify trends and provide recommendations to senior management of process improvements within utilization management Manages and oversees cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Provides training and education to the interdepartmental teams on training needed within the utilization management team based on trends Partners with leadership to improve processes and procedures to prevent recurrences based on industry best practices Provides guidance, subject matter expertise and training as needed Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 5 - 7 years of related experience. Expert knowledge of Medicare and Medicaid regulations preferred. Expert knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required- Compact License Location: Position is remote. Prefer candidate to live in PST time zone. Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST. Pay Range: $35.49 - $63.79 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act$35.5-63.8 hourly Auto-Apply 13d agoNurse Auditor 2
Humana
Nurse job at Humana
Become a part of our caring community and help us put health first The Nurse Auditor 2 performs clinical audit/validation processes to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant and accurate to support optimal reimbursement. The Nurse Auditor 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Nurse Auditor 2 validates and interprets medical documentation to ensure capture of all relevant coding. Applies clinical and coding experience to conduct a clinical validation review of the inpatient medical record to validate billed diagnoses. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. Use your skills to make an impact WORK STYLE: Remote/Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week. Associates are expected to start each day between 6AM and 9AM in their home time zone. Required Qualifications Active Registered Nurse (RN) license in the state they reside. Minimum of 2 consecutive years acute inpatient hospital care experience in critical, intensive care setting within the last 5 years (Not pediatrics or neonatal). For example: ICU, CCU, PCU, med-surg/adult units or a minimum of 2 years DRG Inpatient auditing. NOTE: Inpatient experience does not refer to any other levels of care such as ER, OR, Pre-op, PACU, L&D, mother-baby, behavioral health, SNF, care manager/discharge manager, LTC, rehab, outpatient or office/clinic visits such as wound care, oncology, radiology, interventional radiology, lab, hospice, or home health. In depth knowledge and critical understanding of complex medical diagnoses including, but not limited to, Sepsis (including end-organ failure), Pneumonia, Acidosis, Renal Failure, Encephalopathy, CVA, DKA, MI, etc. Advanced knowledge of MS Office (Word, Excel, etc) Excellent writing, editing, interpersonal, planning, teamwork, and communications skills Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information Ability to work independently and manage workload Customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession Preferred Qualifications Bachelor's Degree in relevant field preferred Inpatient coding certification (AHIMA or AAPC - ex: RHIA, RHIT, CCS, CIS, CIC) Inpatient coding claim experience Prospective payment methodologies, DRG auditing experience Clinical documentation improvement knowledge (CDE, CDEI certification) Additional Information Work at Home Requirements • 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 for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue (formerly Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. 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 or computer 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. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $78,400 - $107,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. About us Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large. 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.$78.4k-107.8k yearly Auto-Apply 7d agoClinical Review Nurse - Concurrent Review
Centene
Remote
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards We are seeking a Clinical Review Nurse - Concurrent Review to join our team! The ideal candidate will bring expertise in: Nurse with a IN or Compact State License Post Acute Care Experience Clinical Review Experience Problem Solving Skills Excellence Communicate Skills Computer Skills Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act$26.5-47.6 hourly Auto-Apply 6d agoClinical Review Nurse - Concurrent Review
Centene
Remote
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. **Applicants for this role have the flexibility to work remotely from their home anywhere in the Central time zone. This role will support Iowa Medicaid members and requires an Iowa or compact nursing license. The work schedule is Monday - Friday, 8am - 5 pm, with rotating weekend / holiday coverage.** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act$26.5-47.6 hourly Auto-Apply 7d agoUtilization Review Nurse I
Centene
Remote
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must have an active New York State clinical license; and a NYS Driver's License or Identification card. Position Purpose: The Utilization Review Nurse I provides first level clinical review for all outpatient and ancillary services requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls; managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity. Acts as liaison between the TRICARE beneficiary and the Network Provider. Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and determination. Completes data entry and correspondence as necessary for each review. Conducts rate negotiation with non-network providers, utilizing appropriate CMAC, DRG, HCPC reimbursement methodologies. Documents rate negotiation accurately for proper claims adjudication. Acts as liaison between the TRICARE beneficiary and the provider, facility and the MTF to utilize appropriate and cost effective medical resources within the direct care and purchased care system. Identifies and refers potential cases to Disease Management, Case Management, Demand Management and Transitional Care. Refers all potential quality issues and grievances to Clinical Quality Management and suspected fraud and abuse to Program Integrity. Performs other duties as assigned Complies with all policies and standards Education/Experience: Graduate of Nursing program; BSN desired or Graduate in Clinical Psychology or Clinical Social Work. Three years clinical experience in a health care environment; managed care experience desired. For Fidelis Care only: NYS RN, OT or PT license required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act$26.5-47.6 hourly Auto-Apply 14d ago
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