Utilization Management Nurse - Retro Midwest 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, 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.

Understands resources and role responsibilities as well as reporting structure.

Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

Follows established guidelines/procedures to ensure all work is compliant with CMS and NCQA requirements.

Promotes collaboration within own team as well as others.

Required Qualifications

Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action

Prior clinical experience preferably in an acute care hospital, skilled or rehabilitation clinical setting

Experience in utilization management or related activities reviewing criteria to ensure appropriateness of care

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

RETRO/ FER experience

Bachelor's degree in nursing (BSN)

MCG/Milliman experience

Health Plan experience

Previous Medicare experience a plus

Compact and Michigan Nursing Licensure preferred

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 are: Monday-Friday 8am-5pm EST

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