Utilization Management Appeals Nurse

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The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Humana is seeking a Part C Grievance & Appeals (G&A) Nurse who will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews the medical documentation, researching claims, benefits, as well as prior determinations pertinent to the appeal and provides a written summary of findings using a template for each case. The associate will be working and collaborating with Humana CIT teams, Vendors, G&A specialists, and Humana Medical Directors on submitted G&A cases.   The G&A Nurse will participate in initiatives which result in improved member outcomes, operational efficiencies, and process improvement opportunities.

Case preparation of Medicare and/or Duals line of business involving expedited, pre-service and post service appeals Apply and implement Medicare, Medicaid, MCG, claims policy and evidence of coverage guidelines for reviews Perform outreach to providers and/or members Utilize multiple systems such as MHK, CGX, MRM, SRO