Utilization Management Nurse - Humana Healthy Horizons

Position Overview

Humana Healthy Horizons is seeking a Utilization Management Nurse who utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Utilization Management Nurse 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.

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, and requires minimal direction and receives guidance where needed.
• Follows established guidelines/procedures.

Requirements

• Active unrestricted Licensed Registered Nurse (RN) in the state of South Carolina or Compact State License with no active disciplinary action.
• Minimum two (2) years of clinical acute care, skilled nursing, rehab, or transitional care experience.
• Prior experience in utilization management.
• Intermediate to advanced proficiency in Microsoft Office applications, including Word, Excel, and PowerPoint.
• Excellent communication skills (written and verbal).
• Ability to work independently under general instructions and with a team.

Preferred Qualifications

• Bachelor's degree.
• Health Plan experience.
• Behavioral Health experience.
• Prior Medicare / Medicaid experience.

Additional Information

• Employment Type: Full time
• Workstyle: Remote, work at home
• Location: Must reside in South Carolina
• Travel: Occasional travel, up to 1 time per quarter.
• Schedule: Typically, Monday through Friday 8:00 am – 5:00 pm Eastern Standard Time (EST).

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must have a minimum 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 with 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.

Interview Format

As part of our hiring process, we will be using exciting interviewing technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers with an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.

• Pre-recorded Voice Interview: If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
• SMS Text Interview: If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes.

Your recorded interview(s) via text and/or pre-recorded will be evaluated by our hiring team.