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Oklahoma City, OklahomaKentuckyNew MexicoNorth CarolinaNorth Dakota
Quick overview
Conduct comprehensive clinical reviews of prior authorization requests for behavioral health services to determine medical necessity and benefit eligibility. Coordinate with healthcare providers and medical directors while documenting findings in clinical systems to ensure regulatory compliance.
Requirements summary
Must be a transitioning service member or military spouse with an active RN license in Kentucky or an eNLC compact license. Requires a minimum of two years of clinical behavioral health experience and proficiency in EMR systems.
bachelor degreeprofessional certificateCase ManagementQuality AssuranceRegulatory ComplianceClinical DocumentationBehavioral HealthInterdisciplinary CoordinationElectronic Medical Records (EMR)Medical Necessity ReviewPrior AuthorizationClinical ReviewUtilization ManagementHealthcare Software
Job description
Become a part of our caring community 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 main training to perform your internship.
You will partner with your team to support members, projects, and to meet goals affecting 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 Utilization Management Behavioral Health Registered Nurse (RN) Intern will report to a manager of the National Medicaid team.
You will use training and engage formerly acquired skillsets to complete medical necessity reviews for behavioral health 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.
Promote communication 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 programs 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, in the state of Kentucky or an enhanced Compact, (eNLC) license without restrictions or disciplinary action.· Minimum two, (2) years of clinical behavioral health experience.
Proficiency in healthcare software and electronic medical records (EMR) systems.
Have 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) SSN Alert Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana's secure website.
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
About
Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. 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.
