Humana

Utilization Management Compliance Registered Nurse, RN

Humana

Louisville, KY, USA
Full-TimeDepends on ExperienceMid-LevelBachelors
Job Description

Welcome to Humana, a leading healthcare company dedicated to improving the well-being of our members and communities. We are currently seeking a highly motivated Utilization Management Compliance Registered Nurse, RN to join our growing team. As a Utilization Management Compliance RN, you will play a critical role in ensuring compliance with regulatory and accreditation requirements related to utilization management processes. Your expertise and attention to detail will help us provide high-quality and cost-effective care to our members. To excel in this role, you must possess a current RN license and have a strong understanding of utilization management guidelines. If you are passionate about making a positive impact in the healthcare industry and have a strong commitment to compliance, we encourage you to apply for this exciting opportunity.

  1. Ensure compliance with all regulatory and accreditation requirements related to utilization management processes.
  2. Conduct regular audits and reviews of utilization management activities to identify potential compliance issues.
  3. Develop and implement policies and procedures to ensure adherence to utilization management guidelines.
  4. Collaborate with other departments to ensure that utilization management processes are in line with overall compliance goals.
  5. Educate and train staff on utilization management compliance requirements and best practices.
  6. Monitor and track utilization management data to identify trends and potential areas for improvement.
  7. Stay up-to-date with changes in utilization management guidelines and regulations to ensure ongoing compliance.
  8. Serve as a subject matter expert on utilization management compliance to internal and external stakeholders.
  9. Collaborate with external auditors and regulatory agencies during compliance audits.
  10. Communicate compliance requirements and updates to relevant departments and staff.
  11. Identify and address any compliance issues or gaps in utilization management processes.
  12. Participate in utilization management committee meetings to provide compliance updates and recommendations.
  13. Maintain accurate documentation and records related to utilization management compliance activities.
  14. Serve as a resource for staff on compliance-related inquiries and issues.
  15. Continuously assess and improve utilization management compliance processes and procedures.
Where is this job?
This job is located at Louisville, KY, USA
Job Qualifications
  • Active Rn License: The Ideal Candidate For This Role Should Hold An Active Registered Nurse License In The State Where They Will Be Working. This Is A Basic Requirement For Any Nursing Position And Ensures That The Candidate Has The Necessary Knowledge And Skills To Perform The Job Effectively.

  • Minimum Of 3 Years Experience In Utilization Management: The Candidate Should Have At Least 3 Years Of Experience In Utilization Management, Preferably In A Healthcare Setting. This Experience Should Include Knowledge Of Medicare And Medicaid Regulations, As Well As Experience With Utilization Review Processes And Medical Necessity Criteria.

  • Knowledge Of Cms Guidelines And Regulations: As A Utilization Management Compliance Rn At Humana, The Candidate Will Be Responsible For Ensuring That All Utilization Review Processes Are In Compliance With Cms Guidelines And Regulations. Therefore, The Ideal Candidate Should Have A Strong Understanding Of These Guidelines And Regulations.

  • Strong Communication And Interpersonal Skills: This Role Requires Frequent Communication With Healthcare Providers, Members, And Other Stakeholders. Therefore, The Candidate Should Have Excellent Verbal And Written Communication Skills, As Well As Strong Interpersonal Skills To Effectively Build Relationships And Work Collaboratively With Others.

  • Attention To Detail And Analytical Skills: Utilization Management Compliance Rns Are Responsible For Reviewing Medical Records And Ensuring That All Documentation Is Accurate And Meets Regulatory Requirements. Therefore, The Candidate Should Have Strong Attention To Detail And Analytical Skills To Effectively Analyze And Interpret Complex Medical Information.

Required Skills
  • Risk Management

  • Quality Assurance

  • Communication

  • Compliance

  • Case management

  • Clinical documentation

  • Utilization management

  • Medical coding

  • Interdisciplinary Collaboration

  • Healthcare Regulations

  • Humana

  • Registered Nurse

Soft Skills
  • Communication

  • Conflict Resolution

  • Emotional Intelligence

  • Leadership

  • Time management

  • creativity

  • Critical thinking

  • Teamwork

  • Adaptability

  • Problem-Solving

Compensation

According to JobzMall, the average salary range for a Utilization Management Compliance Registered Nurse, RN in Louisville, KY, USA is $67,000 - $95,000 per year. This may vary depending on the specific job responsibilities, years of experience, and the employer. Some employers may also offer additional benefits such as bonuses, healthcare coverage, and retirement plans.

Additional Information
Humana is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate based upon race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Required LanguagesEnglish
Job PostedDecember 8th, 2023
Apply BeforeSeptember 18th, 2025
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About Humana

Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. Its strategy integrates care delivery, the member experience, and clinical and consumer insights to encourage engagement, behavior change, proactive clinical outreach and wellness for the millions of people they serve across the country. The company operates its business through the following segments: Retail, Group, and Healthcare Services.

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