Job Closed
This listing is no longer active.
Louisville, Kentucky-based Humana is a leading healthcare company that offers a variety of health, wellness, and insurance products and services designed to off
Preauthorization Registered Nurse
Location
United States + 1 moreAll locations: United States | Trinidad And Tobago
Posted
96 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Preauthorization Registered Nurse
Humana
Become a part of our caring community and help us put health first Are you a transitioning military service member or a military spouse looking for an internship that supports the goal to put health first? The DOW SkillBridge Internship and Military Spouse Fellowship Programs will provide you with key training to perform your internship. You will partner with your team to support members, projects, and to meet goals impacting business outcomes. The professionals you work with at Humana will depend on the type of internship you select. They may include healthcare professionals, HR, and IT, to name a few. The objective is to support and facilitate care for members. To be eligible for this internship, you must either be a transitioning military service member or a military spouse, and you must obtain eligibility to participate in these DOW sponsored programs. The Prior Authorization, Registered Nurse, RN, Intern will report to a manager of the National Medicaid team. You will utilize training and engage formerly acquired skillsets to complete medical necessity reviews for requested services using clinical judgment and provides referrals to internal stakeholders for further review depending on case findings. You will participate in the following assignments in this role: Clinical Review: - Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility. - Apply advanced evidence-based clinical guidelines in review decisions. - Ensure compliance with accreditation, state, and federal regulations. Communication and Coordination: - Communicate with healthcare providers to obtain necessary clinical information and clarify requests. - Coordinate with medical directors and interdisciplinary teams to support decision-making. - Serve as a liaison between clinicians, internal departments, and members. Documentation and Reporting: - Document all review findings and decisions in clinical documentation systems. - Ensure timely and accurate documentation of prior authorization determinations. - Support reporting initiatives and provide data for performance improvement projects. Quality Assurance: - Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions. - Conduct regular audits and reviews to maintain high standards of service. - Identify process improvement opportunities and contribute to performance improvement projects. Education and Training: - Educate providers and staff on prior authorization policies, criteria, and review processes. - Provide mentorship and feedback to nonclinical staff and peers to enhance workflow efficiency. - Stay current with clinical best practices and regulatory changes. Use your skills to make an impact Required Qualifications: - You must be a transitioning service member eligible to participate in the DOW SkillBridge or a military spouse eligible to participate in the military spouse fellowship· - Active Registered Nurse, RN, enhanced Compact, (eNLC) license without restrictions or disciplinary action.· - Minimum two (2) years clinical nursing experience such as acute care, emergency room, ICU, skilled or rehabilitation setting. - Working knowledge of MS Office including Word, Excel, PowerPoint, and Teams in a Windows based environment and an ability to quickly learn new systems and ability to troubleshoot and resolve basic technical difficulties in a remote environment. - Possess an interest in working in the managed care industry Preferred Qualifications: - Bachelor's degree - Previous Medicare/Medicaid experience. - Previous experience in prior authorization, utilization management. - Experience working with MCG or Interqual guidelines. - Certification in Case Management, (CCM) or Utilization Review, (UR). - Knowledge of payer policies, insurance companies and government health programs. Workstyle: Remote Work at Home Location: Must reside in a state that participates in the enhanced compact license, (eNLC) Work Schedule: Weekdays 8:00 AM to 4:30 PM Central Time Travel: None Additional Information Work At Home Requirements - WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense. - A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required. - Satellite and Wireless Internet service is NOT allowed for this role. - A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information The DOW SkillBridge Internship Program provides transitioning military service members time to gain civilian work experience while still on active duty with an employer for a period approved by their command and the DOW, with an average timeline of 90 days. The Military Spouse Fellowship Program connects military spouses with employers offering a variety of professional onsite, field, or remote based opportunities for a period up to 12 weeks. - Networking opportunities will be provided while participating in the Internship or Fellowship. - Due to factors such as location, and/or requirements that cannot be modified, full-time employment is not guaranteed upon completion of the Internship or Fellowship. Interview Format As part of our hiring process, we will be using a screening and interviewing technology provided by HireVue, a third-party vendor. This technology provides our team of recruiters and hiring leaders with an enhanced method for decision-making. If you are selected to move forward from your application prescreen, you will receive an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. (please be sure to check your spam or junk folders often to ensure communication isn't missed) 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 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 1 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.
Job Requirements
- You must be a transitioning service member eligible to participate in the DOW SkillBridge or a military spouse eligible to participate in the military spouse fellowship.
- Active Registered Nurse, RN, enhanced Compact, (eNLC) license without restrictions or disciplinary action.
- Minimum two (2) years clinical nursing experience such as acute care, emergency room, ICU, skilled or rehabilitation setting.
- Working knowledge of MS Office including Word, Excel, PowerPoint, and Teams in a Windows based environment and an ability to quickly learn new systems and troubleshoot basic technical difficulties in a remote environment.
- Possess an interest in working in the managed care industry.
- Bachelor's degree (preferred).
- Previous Medicare/Medicaid experience (preferred).
- Previous experience in prior authorization, utilization management (preferred).
- Experience working with MCG or Interqual guidelines (preferred).
- Certification in Case Management, (CCM) or Utilization Review, (UR) (preferred).
- Knowledge of payer policies, insurance companies, and government health programs (preferred).
Benefits
- Remote Work at Home.
- Must reside in a state that participates in the enhanced compact license, (eNLC).
- Work Schedule: Weekdays 8:00 AM to 4:30 PM Central Time.
- Networking opportunities will be provided while participating in the Internship or Fellowship.
Related Guides
Related Categories
Related Job Pages
More Clinical Operations Jobs
Telephonic Case Manager
SedgwickSedgwick, headquartered in Memphis, Tennessee, provides a global clientele with technology-enabled risk and benefits solutions. Distinguished as an Employer of
By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance Telephonic Case Manager PRIMARY PURPOSE OF THE ROLE: While partnering with the injured worker, employer, and medical providers, create a case management strategy to facilitate medical recovery and a successful return to work through advocacy, communication and coordination of medical services. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. - Apply your medical/clinical or rehabilitation knowledge and experience to assist in the management of complex medical conditions, treatment planning and recovery from illness or injury. - Work in the best of both worlds - a rewarding career making an impact on the health and lives of others, and a remote work environment. - Enjoy flexibility and autonomy in your daily work, your location, and your career path while advocating for the most effective and efficient medical treatment for injured employees in a non-traditional setting. - Enable our Caring counts® mission supporting injured employees from some of the world’s best brands and organizations. - Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. - Celebrate your career achievements and each other through professional development opportunities, continuing education credits, team building initiatives and more. - Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs. ESSENTIAL RESPONSIBLITIES MAY INCLUDE - Performs initial and ongoing clinical assessment via telephone calls to evaluate the injured worker's injury, medical treatment, psychosocial needs, cultural implications and support systems. - Effectively communicates and builds relationships with the claims’ examiner, client, injured worker, attorney and supervisor. - Identifies issues related to delayed recovery and/or return to work and problem solves with a creative thinking approach - Negotiates treatment and disability duration with providers through use of medical and disability duration guidelines, adhering to quality. - Identifies opportunities to expedite care for cost containment and timely medical recovery. - Provides recommendations for alternate clinical resources to support claim resolution. - Maintains client's privacy and confidentiality, promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards. EDUCATION AND LICENSING Current unrestricted RN license(s) in a state or territory of the United States required. Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred. Certification in case management, rehabilitation nursing or a related specialty is highly preferred. TAKING CARE OF YOU BY - Offering a blended work environment. - Supporting meaningful work that promotes critical thinking and problem solving. - Providing on-going learning and professional growth opportunities. - Promoting a strong team environment and a culture of support. - Recognizing your successes and celebrating your achievements. - Thrives when everyone is working towards the same vision/goals. - We offer a diverse and comprehensive benefits package including: - Three Medical, and two dental plans to choose from. - Tuition reimbursement eligible. - 401K plan that matches 50% on every $ you put in up to the first 6% you save. - 4 weeks PTO your first full year. NEXT STEPS If your application is selected to advance to the next round, a recruiter will be in touch. #nurse #telephoniccasemanager As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $73,000 - $75,000. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits. Always accepting applications. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.
Clinical Specialist - MedTech
CVRxCVRx is a medical technology company focused on providing innovative solutions for patients suffering from heart failure. Its flagship product, Barostim, offers a therapeutic optio
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Clinical Specialist at CVRx is responsible for providing clinical support for CVRx technology and business applications through education of current and potential customers, and procedure coverage within a defined region or geography, in partnership with Territory Managers, sales leaders and other key internal partners. As a Clinical Specialist at CVRx, you will play a vital role in supporting our cutting-edge technology while also supporting our commercial team in driving the expansion of our products. - Responsible for effectively communicating product and clinical benefits of Barostim therapy to cardiologists, heart failure/hypertension specialists, and cardiac/vascular surgeons to ensure their understanding of the therapy. - Facilitate trainings and other programs on proper application of Barostim therapy to clinicians, office, and hospital staff. - Provide technical support and troubleshooting during implant procedures, follow-up procedures, titrations, and patient office visits to ensure positive clinical outcomes. - Work with Territory Managers in developing effective plans to communicate the benefits of our technology, tailored to specific markets. - Work with Territory Managers, key physicians and site staff in the development and execution of a plan to effectively launch CVRx programs at new customer sites and ensure ongoing commitment to the program. - Drive utilization and continuous expansion of Barostim therapy through disease state education and supporting the development of therapeutic programs. - Act as a clinical interface between the medical community and the business. - Meet with existing and potential health care providers to identify their clinical needs, goals, and constraints related to patient care, providing creative and feasible solutions. - Adheres to sales management processes and reporting systems usage, including maintaining an accurate record of devices and programmers at all times in Salesforce. - Provide additional back-up support to other field staff as needed. Qualifications - Bachelor’s degree or equivalent combination of education and experience. - Strong interpersonal skills and ability to effectively manage relationships with key customer groups and CVRx staff. - Ability to master concepts of a medical and surgical nature, as well as that of active implantable medical device technology. - Experience with products for cardiology or cardiac surgery therapeutic devices; heart failure experience will be prioritized. - Independent, self-motivated, self-starter with the drive and persistence to introduce a novel and innovative technology to the market and support it becoming the standard of care. - Must be detail-oriented and able to work independently. - Proficient with Microsoft Office and ability to learn Salesforce, content management, learning management, and other systems as needed. Requirements - An advanced degree (preferred). - Healthcare experience beneficial. - Knowledge of heart failure or cardiovascular market with clear understanding of competitive devices, strategies, advantages/disadvantages as they relate to the company’s devices. - Proficient with Microsoft Office and Salesforce, with the demonstrated ability to quickly learn content management, learning management and other systems as needed. - Ability to interact with R&D to represent customer perspective in order to provide input on product enhancements and new product development. Working Conditions - This position is remote-based and will require the candidate to live within the region specified. - This position will require interfacing with multiple internal departments and physician investigators/customers. - Must be able to lift up to 10 lbs. - Ability to travel 60% or more; some overnights may be required. - May be required to be fully vaccinated against the COVID-19 virus and other diseases. Benefits - Competitive salaries and benefits plans. - Health & Dental Insurance options with generous Company contributions. - Company contributions to an HSA if enrolled in a high deductible plan. - 401(k) with company match. - Employee stock purchase plan & stock option grants. - 12 company-paid holidays per year plus generous PTO plan. - Paid time off for new parents. - Company-paid life insurance & disability. - Unlimited growth opportunities. - Training & learning opportunities. - Flexible Schedules.
Clinical Applications Specialist - Cardiovascular Ultrasound
GE HEALTHCAREGE HealthCare is a leading global medical technology and digital solutions innovator. Our purpose is to create a world where healthcare has no limits. Unlock your ambition, turn ideas into world-changing realities, and join an organization where every voice makes a difference, and every difference builds a healthier world.
Job Description Summary As the Cardiovascular Ultrasound (CVUS) Clinical Application Specialist, you will deliver clinical and operational expertise by providing excellent education and training support for the CVUS product portfolio to clinical end-users. Clinical experts facilitate evidence-based practice and support the customer experience and commercial teams from pre-sale through post implementation by providing effective outcome-based education and training solutions. Must reside in Sacramento or Reno. GE Healthcare is a leading global medical technology and digital solutions innovator. Our mission is to improve lives in the moments that matter. Unlock your ambition, turn ideas into world-changing realities, and join an organization where every voice makes a difference, and every difference builds a healthier world. Job Description Roles and Responsibilities - Serve as a subject matter expert (Ultrasound) and technical liaison to the sales organization with the goal of strengthening technical capabilities of the team and customer relationships, while also driving business opportunities forward. - Advance new product (NPI) features and imaging techniques; partner with customers in developing training plans / strategies that support new product assimilation (Ultrasound) and ongoing training needs. - Coordinate, schedule, and execute objective based system training; monitor and report on training outcomes. - Act as focal point for modality / team, identify customer satisfaction issues, assist in escalations, problem determination and specialty training requests. - Develop meaningful relationships with key opinion leaders (KOLs) to standardize and optimize protocols and support our clinical education initiatives. - Penetrate competitive accounts and communicate current market intelligence back to the business, along with field concerns, issues and requirements. - Provide technical and clinical leadership during sales process by demonstrating full range of Ultrasound products including potential uses, product capabilities and benefits to customers. Required Qualifications - Associate degree or equivalent and 2+ years of Ultrasound technical/clinical industry experience plus American Registry of Diagnostic Medical Sonographers (RDCS) certification or CCI registry in Echocardiography. - Demonstrated experience working on cardiac ultrasound systems. - Deep understanding of clinical education training and associated process implementation. - Demonstrated experience delivering complex information and modifying messaging based on audience. - Willingness to travel extensively 75+% (4-5 days per week including 2 - 3 overnights and some weekends) within the US via multiple modes of transportation (car, air travel, & train, etc.). - Reside in Sacramento or Reno. Desired Characteristics - Bachelor’s degree - 3-5 years clinical experience - Demonstrated clinical and technical expertise working on Vivid products - Experience in demonstrating products and solutions to a variety of healthcare audiences - Entrepreneurial thinking to support customers and commercial teams in defined goal for demonstrations with an understanding of the sales process. - Excellent analytical and communication skills with the ability to communicate with employee and internal and external customers at all levels - Exceptional interpersonal skills - Openness to change and process improvement mindset - Reside in Sacremento We expect all employees to live and breathe our behaviors: to act with humility and build trust; lead with transparency; deliver with focus, and drive ownership –always with unyielding integrity. Our total rewards are designed to unlock your ambition by giving you the boost and flexibility you need to turn your ideas into world-changing realities. Our salary and benefits are everything you’d expect from an organization with global strength and scale, and you’ll be surrounded by career opportunities in a culture that fosters care, collaboration and support. #LI-MA4 We will not sponsor individuals for employment visas, now or in the future, for this job opening. For U.S. based positions only, the pay range for this position is $124,240.00-$186,360.00 Annual. It is not typical for an individual to be hired at or near the top of the pay range and compensation decisions are dependent on the facts and circumstances of each case. The specific compensation offered to a candidate may be influenced by a variety of factors including skills, qualifications, experience and location. In addition, this position may also be eligible to earn performance based incentive compensation, which may include cash bonus(es) and/or long term incentives (LTI). GE HealthCare offers a competitive benefits package, including not but limited to medical, dental, vision, paid time off, a 401(k) plan with employee and company contribution opportunities, life, disability, and accident insurance, and tuition reimbursement. Additional Information GE HealthCare offers a great work environment, professional development, challenging careers, and competitive compensation. GE HealthCare is an Equal Opportunity Employer. Employment decisions are made without regard to race, color, religion, national or ethnic origin, sex, sexual orientation, gender identity or expression, age, disability, protected veteran status or other characteristics protected by law. GE HealthCare will only employ those who are legally authorized to work in the United States for this opening. Any offer of employment is conditioned upon the successful completion of a drug screen (as applicable). While GE HealthCare does not currently require U.S. employees to be vaccinated against COVID-19, some GE HealthCare customers have vaccination mandates that may apply to certain GE HealthCare employees. Relocation Assistance Provided: No
Overview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. The Clinical Triage Nurse works in a fast-paced call center environment and utilizes a patient-centered approach to direct patients to the appropriate level of care based on the severity of their clinical need by using protocols and algorithms. The Clinical Triage Nurse will communicate with patients, families, physicians, and support staff as appropriate. The Clinical Triage Nurse will be responsible for developing relationships with associated contact center teams, clinical practices (including on-site support and virtual meetings) and connected resources. EEO/AA/Disability/Veteran Responsibilities - 1. Performs telephonic triage to a diverse patient population using best practice clinical protocols and when indicated standing orders or use of referral trees to assist the patients to the appropriate level of care. - 2. Collaborates with wide array of healthcare clinicians and resources to secure time-sensitive response to patients with an objective of a one call resolution, when applicable. - 3. Use effective communication skills in interacting with providers, patients, and families to correctly assess an individual's needs and capabilities in order to successfully facilitate information exchange and guide next steps. - 4. Follow up with patients providing test results, education, escalation or triage for medical management of symptoms when appropriate. - 5. Apply clinical assessment and communication skills while adhering to established clinical guidelines. - 6. Follows established call management guidelines, perform complete, accurate and timely documentation and data entry for all clinical activity in accordance with standards. - 7. Consistently demonstrate ability to respond to changing situations in a flexible manner to meet current needs, such as reprioritizing work as necessary. - 8. Identify needs and make appropriate recommendations for quality improvement which creates perceived value for customers. - 9. Maintain strict patient confidentiality. - 10. Continuously expand knowledge and understanding of community resources while assisting patients to access and utilize available/appropriate resources available. Maintain working knowledge of regional community resources (Urgent Cares, Walk in Care, video Care, Emergency Departments, etc). - 11. Works independently and maintains competence in nursing care. - 12. Obtains all requested clinical documentation. - 13. Coaches, trains, and mentors new and existing triage staff. Provides routine feedback and oversight of Health Advisors. - 14. Demonstrates patient service excellence at all times. - 15. Build and maintain positive working relationships with patients and clinical triage team. Maintain a visible role within the clinical practices to foster collaboration with providers and staff. Ensure an understanding of clinic specific workflows and procedures to maintain adherence to updated protocols. - 16. Performs quality assessments to ensure proficiency in the specialized skills of triage nursing and adherence to productivity, efficiency, and patient experience standards. - 17. Other duties as assigned. Qualifications EDUCATION Graduate of an accredited school of Nursing. RN required. Bachelor's or master's degree in nursing preferred. EXPERIENCE 3 years of clinical experience in direct patient care required. Triage or ICU/ED experience preferred. LICENSURE Registered Nurse license in the state of Connecticut required. Basic Life Support (BLS) certification and Advanced Cardiopulmonary Life Support (ACLS) per departmental policies. SPECIAL SKILLS Ability to triage non-urgent and emergent situations. Working knowledge and ability to apply professional standards of practice in a work environment. Excellent interpersonal and customer service skills, strong ability to educate, and excellent communication written and verbal skills. Must be organized and able to prioritize competing tasks while working collaboratively. Basic computer skills. Proficient in various word processing, spreadsheet, and database programs, including Microsoft Word, Excel, PowerPoint, Outlook, etc. PHYSICAL DEMAND Work is preformed both on-site and remote. Requires ability to operate standard office equipment. YNHHS Requisition ID 168161
