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Compliance Nurse / UM Nurse - Central Region

Saint Louis, MO

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Compliance Nurse / UM Nurse - Central Region

Saint Louis
Job #683105026
Role: Compliance/Utilization Management RN
Assignment: Sr. Segment
Location: Central Region - Des Peres, MO, Overland Park KS, Rogers, AR or Tulsa, OK
Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana’s Perfect Service® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.
Assignment Capsule
Be a part of our Clinical Space – as a Clinical Advisor you will engage our members to develop lifelong wellbeing and health.
Humana is seeking a Compliance/Utilization Management RN who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.
Reviews denied, approved, and appealed authorizations for completeness and compliance in documentation for Central Region
Review daily “Expedited Authorization” report and “Manual Approval” report and follows up with staff and leadership on authorizations needing corrections.
Ensure Compliance in Documentation and other areas for Medicare Denials
Train other RN's on Medicare Compliances
Compose, edit and send letters
Work with Regional Medical Directors on Medicare Denials
Monitor and manage database through Microsoft Access
Help with the daily report management
Partner with the team to achieve successful compliance timeframes, enhancement of workflows and processes
Be available for educating staff on a “one on one” basis or as a group to new compliance changes or as educational needs arise.
Work within interdisciplinary team
Role Essentials
Active RN license
Ability to be licensed without restrictions
Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
Utilization Review Experience
Ability to work independently under general instructions and with a team
Time management
Strong organizational skills
Strong attention to details
Strong Computer skills with the ability to multitask and work out of multiple systems
Strong verbal and written communication skills
Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 10Mx1M.
Role Desirables
Education: BSN or Bachelor’s degree in a related field
Medicare/CMS experience
Compliance experience
Health Plan experience
Previous Medicare Experience a plus
Call center or triage experience
Bilingual is a plus
Additional Information
Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.
To be entered by a recruiter.
Compliance Nurse / UM Nurse - Central Region
Kansas-Overland Park
Other Locations:
US-Oklahoma-Tulsa, US-AR-Rogers, US-Missouri-Des Peres
Requisition ID:
**MEMBERS ONLY**SIGN UP NOW***., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.
Updated 06/12/2018

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