• Humana
  • $75,110.00 -99,350.00/year*
  • Phoenix, AZ
  • Healthcare - Nursing
  • Full-Time
  • 332 W Monroe St

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Description

The Telephonic Front End Review Nurse reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Telephonic Front End Review Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Telephonic Front End Review Nurse ensures mandatory reporting completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. 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.


Ideal Skillset

The ideal candidate for this position will live in the CO, AZ or NM area; have an active and unrestricted registered nursing license, BSN preferred; acute care experience, familiarity with MCG/Milliman/Interqual/CMS guidelines; background using Electronic Medical Record (EMR) systems; and strong computer acumen using MS Office products. This role will also require working 2 weekends per month.

Required Qualifications

  • Active RN license in the state(s) in which the nurse is required to practice
  • Must be able to work 2 weekends per month
  • At least 3 years of varied clinical nursing experience
  • Proficient with Microsoft Office products including Word, Excel and Outlook
  • Ability to work independently under general instructions and with a team
  • Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required
  • Ability to provide a designated workspace; free from distractions with the ability to secure any protected information.
  • Associates working in the state of Arizona must comply with the Tobacco Free Hiring Policy (see details below under Additional Information) and upon offer will be subjected to nicotine testing as part of a 10 panel drug test


Preferred Qualifications

  • Bachelor's degree
  • Previous experience in acute care
  • Familiarity with CMS criteria
  • Telephonic care coordination experience
  • Prior use of MCG/Milliman or Interqual guidelines
  • Experience using Electronic Medical Records (EMR)
  • Health Plan experience
  • Previous Medicare/Medicaid Experience a plus
  • Prior case management experience
  • Bilingual is a plus

Additional Information

The following policy applies ONLY to associates working in the state of Arizona: Humana is committed to providing a safe and healthy work environment and to promoting the health and well-being of its associates. Effective April 1, 2011, Humana has adopted a tobacco-free hiring policy that will promote a healthier workplace and will not hire users of tobacco and nicotine products. If you have any questions, please consult with your recruiter.


Scheduled Weekly Hours

40

Associated topics: ambulatory, bsn, cardiothoracic, ccu, intensive care unit, neonatal, recovery, registed, surgery, unit

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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