Utilization Management Nurse (Gulf South 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.

• Review UM inpatient admission and clinical information to determine appropriate level of care
• Follows established guidelines/procedures
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
• Coordinates and communicates with providers, members, or other parties to facilitate appropriate discharge planning including to assist with social determinants and closing gaps

Required Qualifications

• Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action
• Excellent communication skills both verbal and written
• 3-5 years of 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
• Comprehensive knowledge of Microsoft Word, Outlook and Excel
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Milliman MCG experience preferred
• Bachelor’s Degree (BSN)
• Compact nurse licensure preferred
• Experience in utilization management or related activities reviewing criteria to ensure appropriateness of care preferred
• Previous Medicare experience a plus
• Health Plan experience

Work-At-Home Requirements

• 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
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
• 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
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job

Additional Information

• Hours are: Monday-Friday 8am-5pm CST or EST, overtime and a weekend rotation may be required based on a business need

#LI-Remote

Scheduled Weekly Hours

40