Utilization Management Nurse

Humana • Work at Home - Ohio, OH

4d • $71,100 - $97,800 • Remote

About The Position

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. The Utilization Management Nurse 2 uses clinical knowledge 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. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Requirements

• Bachelor's degree
• Licensed Registered Nurse (RN) in the state of Ohio with no disciplinary action.
• At least 3 years of Medical Surgery, Heart, Lung or Critical Care Nursing experience.
• Previous experience in utilization management.
• Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Self-provided internet service must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice To Haves

• 3 or more years experience in a high volume community or mail order pharmacy practice environment
• Health Plan experience
• Previous Medicare/Medicaid Experience
• Call center or triage experience
• Bilingual

Responsibilities

• Support the coordination, documentation and communication of medical services and/or benefit administration determinations.
• Interpret criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.
• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Make decisions regarding own work methods and requires minimal direction.

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level