Utilization Management Nurse South Central Region

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