Company name
Humana Inc.
Location
Pittsburgh, PA, United States
Employment Type
Full-Time
Industry
Healthcare, Nursing
Posted on
May 09, 2023
Profile
Description
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.
Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment
Coordinates and communicates with providers, members, or other parties to facilitate appropriate discharge planning including to assist with social determinants and closing gaps
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
Follows established guidelines/procedures
Required Qualifications
Licensed Registered Nurse (RN) Compact license or licensure in all 3 of these states Arkansas, Oklahoma and Texas, with no disciplinary action
At least 3 years of varied clinical nursing experience
Utilization management experience which includes following MCG/Milliman or Interqual guidelines
Prior clinical experience preferably in an acute care, hospital, skilled or rehabilitation clinical setting
Comprehensive knowledge of Microsoft Word, Outlook and Excel
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
Preferred Qualifications
Bachelor's degree in nursing (BSN)
CCM Certification
Health Plan experience
Previous Medicare/Medicaid Experience
Call center or triage 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
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
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
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Company info
Humana Inc.
Website : http://www.humana.com