Clinical Advisor RN

Company: Humana
Location: Charlotte, NC
Employment Type: Full Time

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: Clinical Advisor RN
Assignment: Market Quality Operations
Location: North Carolina - Work at Home

Are you a fit?
You will collaborate with other Humana departments and our network providers as it relates to Quality of care concerns as well as participate in activities associated with HEDIS, CAHPS, HOS, Commercial , CMS, NCQA and any other compliance requirements for the Health Plan

  • Address and quality of care concerns for our members in the assigned territory.
  • Recommend actions for Humana Plan providers which would have a positive effect on their HEDIS and CAHPS and HOS scores.
  • Identify and recommend alternatives, if appropriate, for our providers as they deliver care to Humana members
  • Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions
  • Conduct clinical studies when appropriate, to identify trends of care
  • Become known as a positive representative as well as a resource for our providers and when appropriate, our members for Humana Health Plans

Key Competencies
  • Leveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
  • 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.
  • Is Accountable: You meet clearly stated expectations and take responsibility for achieving results.
  • Clinical Knowledge: You understand clinical program design, implementation, management/monitoring to support choice in consumer medical care. Understands the medical utilization implications of such programs
  • Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.

Role Essentials
  • Active RN license in the state(s) in which the nurse is required to practice
  • Ability to be licensed in multiple states without restrictions
  • Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
  • Ability to work independently under general instructions and with a team
  • Valid drivers license Frequent travel by car required Occasional overnight stays

Role Desirables
  • Education: BSN or Bachelors degree in a related field
  • Health Plan experience
  • Previous Medicare/Medicaid Experience a plus
  • Previous experience in quality or utilization management. Knowledge of HEDIS specifications and medical records review a plus.
  • Bilingual is a plus

    Reporting Relationships
    You will report to a Manager or Supervisor. This area is under the leadership of the SVP & Chief Operating Officer.

    Job Code: 46157
    Category: Health Care
    Post Date: Monday, August 29, 2011 at 5:01 AM
    Company: Humana
    Contact Name:

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