UM BH Registered Nurse

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 key training to perform your internship. You will partner with your team to support members, projects, and to meet goals impacting business outcomes. Professionals you work with may include healthcare professionals, HR, IT, and others to support and facilitate care for members. To be eligible, you must either be a transitioning military service member or a military spouse and obtain eligibility to participate in these DOW-sponsored programs. Internship Details The Utilization Management Behavioral Health Registered Nurse (RN) Intern will report to a manager of the National Medicaid team. You will utilize training and engage formerly acquired skillsets to complete medical necessity reviews for behavioral health requested services using clinical judgment and provide referrals to internal stakeholders for further review depending on case findings. Assignments 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. Communicate with healthcare providers to obtain necessary clinical information and clarify requests. Coordinate with medical directors and interdisciplinary teams to support decision‑making. Serve as a liaison between clinicians, internal departments, and members. Document all review findings and decisions in clinical documentation systems. Ensure timely and accurate documentation of prior authorization determinations. Support reporting initiatives 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. Required Qualifications Transitioning service member eligible to participate in the DOW SkillBridge or a military spouse eligible for the fellowship. Active Registered Nurse (RN) in Kentucky or an enhanced Compact (eNLC) license without restrictions or disciplinary action. Minimum two (2) years of clinical behavioral health experience. Working knowledge of MS Office and ability to learn new systems and troubleshoot basic technical difficulties in a remote environment. Proficiency in healthcare software and electronic medical records (EMR) systems. Interest in working in the managed care industry. Preferred Qualifications Bachelor's degree. Previous Medicare/Medicaid experience. Experience in prior authorization, utilization management. Experience 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 and Location Remote work at home. 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. No travel required. Additional Requirements High‑speed DSL or cable modem for a home office (minimum 25Mbps download x 10Mbps upload). Satellite and wireless internet not allowed. A dedicated, interruption‑free space to protect member PHI/HIPAA information. 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. #J-18808-Ljbffr