Clinical Quality Consultant, RN - Embedded - St. Louis, MO
Location: Des Peres, Missouri
Description: Humana is hiring Clinical Quality Consultant, RN - Embedded - St. Louis, MO right now, this occupation will be depute in Missouri. For complete informations about this occupation opportunity please read the description below. Be a part of our Clinical Space- Provide guidance to facilitate interaction or services that connect people with lifelong well-being.
Humana is seeking an Embedded Case Manager - RN who will work with identified members to assess their care needs, assist in planning and implementing interventions to meet those needs, assist in coordinating services, and monitor and evaluate the case management plan against the member’s personal healthcare goals.
You will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.
Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using your knowledge of benefit plan design
Recommend services for Humana Plan members using care alternatives available within the community and nationally
Examine clinical programs information to: manage our members on an outpatient basis and develop strategies to prevent readmission; mine health risk assessment data reports to identify potentially high-risk membership; identify and refer members to Disease Management Programs; conduct discharge planning; coordinate Behavioral Health management
Coordinate: in versus out-of-network movement; care in out-of-network facilities; care with specialty networks; care with DME providers; transfers to SNF and back
Conduct post-discharge calls and discharge planning
Key Competencies
Builds Trust: Consistently models and inspires high levels of integrity in decisions, speech, and actions. Lives up to commitments, taking responsibility for the impact of one's actions. Exercises the courage to prioritize principles and values over personal or professional gain.
Accountability: Meets established expectations and takes responsibility for achieving results; encourages others to do the same. Employs focus, attention to detail, reliability, and appropriate prioritization to drive outcomes. Sees opportunities to contribute and takes the initiative to create solutions.
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. Develops and strengthens networks and relationships, both inside and outside the organization, that support company performance. Proactively and transparently contributes information and energy toward creating value with others.
Executes for Results: Effectively leverages resources to create exceptional outcomes. Determines the best course of action when facing ambiguity. Anticipates and constructively resolves barriers and constraints. Embraces change, applies new knowledge and reconfigures quickly to capitalize on opportunities.
Role Essentials
Current RN license in the state in which the nurse will be required to practice
Ability to be licensed in multiple states without restrictions
Previous Case Management experience
2-5 clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
Ability to work independently under general instructions and with a team
Valid driver’s license and/or dependable transportation necessary (variable)
Role Desirables
Education: BSN or Bachelor’s degree in a related field
Special Certifications: Case Management Certification
Health Plan experience
Medicaid/Medicare experience
Call center or triage experience
Bilingual is a plus
Reporting Relationships
You will report to a Provider Engagement Clinical Leader. This area is under the leadership of the SVP & Chief Operations Officer.
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.
Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.
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If you were eligible to this occupation, please deliver us your resume, with salary requirements and a resume to Humana.
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This occupation starts available on: Mon, 22 Jan 2018 21:12:47 GMT