Utilization Management Nurse (South 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.

• Follows established guidelines/procedures
• 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
• Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas

Required Qualifications

• At least 3 years of varied clinical nursing experience
• Prior clinical experience preferably in an acute care, hospital, skilled or rehabilitation clinical setting
• Utilization management experience which includes following MCG/Milliman or Interqual guidelines
• Licensed Registered Nurse (RN) Compact license or licensure in all 3 of these states Arkansas, Oklahoma and Texas, with no disciplinary action
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Comprehensive knowledge of Microsoft Word, Outlook and Excel
• Ability to work independently under general instructions and with a team

Preferred Qualifications

• Health Plan experience
• Previous Medicare/Medicaid Experience
• Bachelor's degree in nursing (BSN)
• CCM Certification
• Call center or triage experience

Work-At-Home Requirements

• Satellite, cellular and microwave connection can be used only if approved by leadership
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job
• 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
• 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 for this role are: Monday-Friday 8am-5pm CST, overtime or weekend work may be required based on a business need

#LI-Remote

Scheduled Weekly Hours

40