RN, Utilization Management - Behavioral Health

About the position The Utilization Management Behavioral Health Nurse at Humana plays a crucial role in supporting the coordination, documentation, and communication of medical services within the behavioral health domain. This full-time remote position allows nurses to work from anywhere in the United States, providing flexibility while ensuring that health remains a priority. The nurse will utilize their behavioral health knowledge and skills to conduct thorough medical record reviews, assess discharge plans, and extract pertinent information from claims. This role requires independent judgment and the ability to interpret complex information to determine appropriate courses of action. The nurse will be responsible for completing documentation for quality reviews and peer reviews, discussing cases with medical directors, and collaborating with other members of the Humana interdisciplinary team. Compliance with performance and reporting standards set by Humana is essential, and the nurse may also take on additional responsibilities as assigned by leadership. The department operates Monday through Friday from 7:00 AM to 5:30 PM CST, with specific hours to be determined based on business needs during the interview process. Responsibilities • Complete medical record reviews from Behavioral Health Facilities to obtain sufficient clinical information. , • Assess discharge plans to ensure appropriate follow-up care. , • Review and extract information from claims for accuracy and completeness. , • Complete documentation for Quality Reviews and Peer Reviews as required. , • Discuss cases with Medical Directors to ensure proper care coordination. , • Work in partnership with other members of the Humana Interdisciplinary team to provide comprehensive care. , • Comply with performance and reporting standards as defined by Humana. , • Complete additional responsibilities as deemed appropriate by Humana leadership. Requirements • Minimum of Associate's Degree in Nursing. , • Registered nurse with active Compact Licensure and no disciplinary actions. , • Minimum 3 years of post-degree clinical experience in direct patient care (either medical or behavioral health). , • Adept experience working with computers, including proficiency with Microsoft Office products: Word, Excel, MS Teams, and OneNote. Nice-to-haves • Advanced nursing degree: BSN or MSN. , • Behavioral Health direct patient care experience preferred. , • Utilization management experience, performing medical necessity reviews against criteria such as MCG, ASAM, Interqual, etc. , • 1 year of managed care experience working directly with insurance companies. , • Use of EMR systems. , • Additional Non-compact nursing licenses. , • Bilingual (English/Spanish); speaking, reading, writing, interpreting and explaining documents in Spanish. Benefits • Benefits starting day 1 of employment , • Competitive 401k match , • Generous Paid Time Off accrual , • Tuition Reimbursement , • Parent Leave , • Medical, dental and vision benefits , • Short-term and long-term disability , • Life insurance , • Paid parental and caregiver leave , • Volunteer time off , • Company and personal holidays Apply Job!