Utilization Review Jobs in Raleigh, NC (NOW HIRING)

Become a part of our caring community and help us put health first
This is an onsite role reporting to the Branch Director of the Portland/Lake Oswego branch.

**Sign-On Bonus of $10,000**

** This position is eligible for relocation assistance. The specific package offered will vary based on individual circumstances and company policy.**

As Clinical Manager, you will manage all direct care patient services provided by clinical personnel.

• Develop, plans, implements, analyzes, and organizes clinical operations for a specific location managed.
• Conduct/delegate the assessment and reassessment of patients, including updating of care plans and interpreting patient needs, while following company, physician, and/or health facility procedures/policies.
• Manage the assignment of caregivers.
• Responsible for and oversees the delivery of care to all patients served by the location. Receive case referrals. Review available patient information related to the case, including disciplines required, to determine home health or hospice needs. Accountable to ensure patients meet admission criteria and make the decision to admit patients to service. Assign appropriate clinicians to a case.
• Instruct and guide clinicians to promote more effective performance and delivery of quality home care services, and is available during operating hours to assist clinicians.
• Assist clinicians in establishing immediate and long-term therapeutic goals, in setting priorities, and in developing patient Plan of Care (POC).
• Monitor cases to ensure documentation is in compliance with regulatory agencies and requirements of third-party payers. Ensure final audits/billing are completed timely and in compliance with Medicare regulations.
• Coordinate communication between team members/attending physicians/caregivers to ensure the appropriateness of care and outcome planning.
• Work together with the Branch Director and Company Finance Department to establish location's revenue and budget goals.
• Participate in sales and marketing initiatives.
• Supervise all clinical employees assigned to a specific location. Responsible for the direction, coordination, and evaluation of the location. Carry out supervisory responsibilities following Company policies and procedures.
• Handle necessary employee corrective action and discipline issues fairly and objectively, in consultation with the Human Resources Department and the Executive Director/Director of Operations.
• Participate in the interviewing, hiring, training, and development of direct care clinicians. Evaluate their performance relative to job goals and requirements.
• Coach staff and recommends in-service education programs, when needed.
• Ensures adherence to internal policies and standards.
• Assess staff education needs based on the review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and conducts regular staff education.
• Analyze situations, identify problems and evaluate alternative courses of action through the use of Performance Improvement principles.
• Responsible for reviewing the appropriate number of Case Managers and clinical staff documentation. This documentation includes starts-of-care, resumption-of-cares, and re-certifications, which are reviewed for appropriateness of care, delivery, and documentation requirements.
• Responsible for the QA/PI activities. Work with Utilization Review staff relative to data tracking for performance review and outcomes of care analysis to determine efficiency, the efficacy of case management system and any other systems and process. Competently perform patient care assignments and staff management activities.
• Provide direct patient care on an infrequent basis and only in times of emergency.
• Act as Branch Director in their absence.
• Interpret Company standards and Company policies and procedures to ensure compliance with external regulatory authorities and ensure that caregiver clinical documentation meets internal standards.
• Participate in performance improvement activities, maintain ongoing clinical knowledge through internal and external training programs. Provide interpretation of knowledge and direction to staff.
• Maintain relationships with referral/community sources. Participate in professional organizations and conduct care-related programs.

Use your skills to make an impact

Required Experience/Skills:

• Graduate of an accredited School of Nursing.
• Current state license as a Registered Nurse.
• Proof of current CPR.
• Valid driver's license, auto insurance and reliable transportation.
• Two years as a Registered Nurse with at least one-year of management experience in a home care, hospice or equivalent environment.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$92,600 - $127,400 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About Us
About CenterWell Home Health: CenterWell Home Health specializes in personalized, comprehensive home care for patients managing a chronic condition or recovering from injury, illness, surgery or hospitalization. Our care teams include nurses, physical therapists, occupational therapists, speech-language pathologists, home health aides, and medical social workers - all working together to help patients rehabilitate, recover and regain their independence so they can live healthier and happier lives.About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first - for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

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.