Utilization Management Nurse (Central Region)

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

Creating Healthy Communities is good for the Soul. Join Us! The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.

• Promotes collaboration within own team as well as others
• Understands resources and role responsibilities as well as reporting structure
• Follows established guidelines/procedures to ensure all work is compliant with CMS and NCQA requirements
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
• Coordinates and communicates with providers, MDs, and administrative staff to facilitate optimal care and treatment
• Review UM inpatient admission and clinical information to determine appropriate level of care in a fast-paced environment

Required Qualifications

• Prior clinical experience preferably in an acute care, hospital, skilled or rehabilitation clinical setting
• Ability to work independently under general instructions and with a team
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• 2-5 years of acute care nursing experience
• Licensed Registered Nurse (RN) Compact State Licensure and/or Illinois or Minnesota License with no disciplinary action
• Comprehensive knowledge of Microsoft Word, Outlook and Excel

Preferred Qualifications

• Utilization Management experience highly preferred
• Bachelor's degree in nursing (BSN)
• MCG/Milliman experience
• Health Plan experience
• Previous Medicare Experience

Work-At-Home Requirements

• Satellite, cellular and microwave connection can be used only if approved by leadership
• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information

• Hours are: Monday-Friday 7am-5pm CST, there is some flexibility with schedules

#LI-Remote

Scheduled Weekly Hours

40