Medical Review - Clinical Advisor – Louisville

Humana Inc., headquartered in Louisville, Kentucky, is one of the nation's largest publicly traded health benefits companies. Humana offers a diversified portfolio of health insurance products and related services - through traditional and consumer-choice plans - to employer groups, government-sponsored plans, and individuals.

Today, Humana is a leader in consumer engagement. Throughout its diversified customer portfolio, the company provides guidance that can both help lower costs and lead to a better health plan experience.

Role: Service Operations Clinical Advisor-RN
Assignment: Medicare Private Fee for Service
Location: Louisville, KY

Are you a fit?
Are you an analytical thinker and a self-starter? Would you enjoy using your medical knowledge to evaluate claims from Humana's customers and partners?

Assignment Capsule
As a medical review clinical advisor you will: research, evaluate and recommend appropriate health solutions, providing accurate and effective information to satisfy the medical concerns, questions and issues of Humana's customers and partners.

• Provide support for the Claims Adjusting and Customer Service areas of the service center by performing retrospective claim reviews and reconsiderations
  
• Research new procedures and products, appropriate drug use, and both claims and contracts to help determine appropriate coverage levels
  
• Prepare medical necessity reviews for the Regional Medical Director, external review organizations or peer reviewers with thoroughness, accuracy and effectiveness

• Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.
  
• Leveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
  
• Implementation/Execution: You are good at organizing and managing multiple priorities and/or projects by using appropriate methodologies and tools.
  
• Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.

• Registered Nurse
  
• Prior longevity in a nursing role
  
• With demonstrated case management experience

• Comprehensive knowledge of Microsoft Word and Excel
  
• Experience with Lotus Notes

• You will report to a Frontline Leader. This area is under the leadership of the SVP & Chief Operating Officer.