Utilization Management Nurse 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, 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) Compact State Licensure and/or Illinois or Minnesota License with no disciplinary action
2-5 years of acute care nursing experience
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)
Utilization Management experience highly preferred
MCG/Milliman experience
Health Plan experience
Previous Medicare 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 are: Monday-Friday 7am-5pm CST, there is some flexibility with schedules


#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 ****

Company info

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