UM Behavioral Health Nurse

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.

The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Behavioral Health Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Utilization Management Behavioral Health Nurse uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Nursing license is required. 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.

Complete medical record reviews for Behavioral Health Inpatient and Outpatient Provider Disputes Cross train in Physical Health Provider Disputes based on the business need Review and extract information from claims Work in partnership with other members of the Humana Interdisciplinary team Comply with performance and reporting standards as defined by Humana Complete additional responsibilities as deemed appropriate by Humana leadership Our department is available Monday – Friday from 6:00 AM-6:00 PM EST. Hours for this role are based on business need between that timeframe