Medicare Appeals Nurse -- Clinical Advisor

Role: Medicare Appeals Nurse -- Clinical Advisor Assignment: Medicare Clinical Physican Review Location: Work at home -- EST Time Zone

Humana's dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana's Perfect Service means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.

Assignment Capsule

Be a part of our Clinical Space -- as a Clinical Advisor you will engage our members to develop lifelong wellbeing and health.

Humana is seeking a Medicare Appeals Nurse who will assist in the preparation of Part C Grievance and Appeal cases prior to review by the Humana Medicare Medical Directors. You will also work closely with Humana Medical Directors, Humana Key Stakeholders and Market Offices. In this role you will:

Prepare medical necessity reviews; involving expedited, pre-service and post service requests

Apply and implement Medicare, Medicaid, Humana coverage policies, Member handbook, Provider handbook, claims policy and evidence of coverage guidelines for reviews

Spend extensive time collaborating with Medical Directors and Key Stakeholders on case reviews

Utilize CGX, CCP2, Outlook, etc. to open and review cases on daily basis

Key Competencies

Builds Trust: Consistently models and inspires high levels of integrity, lives up to commitments, and takes responsibility for the impact of one's actions.

Accountability: Meets established expectations and takes responsibility for achieving results; encourages others to do the same.

Collaborates: Engages others by gathering multiple views and being open to diverse perspectives, focusing on a shared purpose that puts Humana's overall success first.

Executes for Results: Effectively leverages resources to create exceptional outcomes, embraces change, and constructively resolves barriers and constraints.

Role Essentials

Licensed Registered Nurse

4 Years broad clinical experience

3 or more years' experience in the health industry and ability to understand claims coding

Extensive understanding of Medicare regulations

Role Desirables

Bachelor's degree

Health plan experience

SIU experience

Knowledge of CPT code billing

Certified Professional Coder (CPC)

Medicaid experience a plus

Knowledgeable in Humana Clinical Systems; CCP2, CGX, Claims, etc.

Additional Information

At Humana, we know your well-being is important to you, and it's important to us too. That's why we're committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. If you share our passion for helping people, we likely have the right place for you at Humana.

After applying, we encourage you to join our Talent Network as well, so you can stay informed and up to date on what's happening around our organization in the changing world of healthcare.