Utilization Management Nurse 2

Position Overview

Become a part of our caring community and help us put health first. The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. This role involves varied work assignments that frequently require interpretation and independent determination of the appropriate courses of action. The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking to interpret criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for members.

Responsibilities

• 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.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, requiring minimal direction and receiving guidance where needed.
• Follows established guidelines/procedures.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences.
• Use your skills to make an impact.

Requirements

• Required Qualifications:

  • Active enhanced Registered Nurse, (eNLC) license (RN) with no disciplinary action.
  • Ability to obtain multiple state registered nurse licenses.
  • Minimum three (3) years of Medical Surgery, Heart, Lung, maternity/obstetrics, or Critical Care Nursing experience required.
  • Prior clinical experience preferably in an acute care, skilled, or rehabilitation clinical setting.
  • Intermediate to advanced knowledge of Microsoft Word, Outlook, and Excel, systems, and platforms.
  • Ability to work independently under general instructions and with a team.

• Preferred Qualifications:

  • Bachelor's degree.
  • Previous experience in prior authorization, claims, and/or utilization management in healthcare, health insurance, evaluating medical necessity and appropriateness of care.
  • Health Plan experience.
  • Previous Medicare/Medicaid Experience a plus.
  • Bilingual is a plus.

Workstyle & Schedule

• Location Type: Remote work at home.
• Location: Must reside in a state that participates in the enhanced nurse licensure, (eNLC).
• Schedule: Monday through Friday 8:00 AM to 5:00 PM Eastern, with the ability to work overtime and weekends as needed to support business needs.
• Travel: Less than 5%.

Additional Information

• Salary: Not specified.
• Employment Type: Full-time.
• SSN Alert: Humana values personal identity protection. Applicants may be asked to provide their Social Security Number if it is not already on file. An email will be sent from Humana@myworkday.com with instructions if required.
• Interview Format: HireVue interviewing technology will be used.
• Work at Home Guidance:
  • Internet Service: Minimum download speed of 25 Mbps and upload speed of 10 Mbps required. Wireless, wired cable, or DSL connection suggested. Satellite, cellular, and microwave connections may be used only if approved by leadership.
  • Internet Expense: Employees living and working from Home in California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
  • Telephone Equipment: Humana will provide appropriate telephone equipment.
  • Work Space: Must work from a dedicated space lacking ongoing interruptions to protect member PHI.