Utilization Management, Nurse

Humana•Work at Home - South Carolina, SC

2d•$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 benefit administration determinations. This role involves varied work assignments that frequently require interpretation and independent determination of 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. This role also involves coordinating and communicating with providers, members, or other parties to facilitate optimal care and treatment, and understanding department, segment, and organizational strategy and operating goals, including their linkages to related areas. The role follows established guidelines and procedures.

Requirements

Licensed Registered Nurse (RN) in South Carolina with no disciplinary action.
3+ years of Medical Surgery, Heart, Lung or Critical Care Nursing experience required.
Must reside in South Carolina.
Able to work rotational weekends.
Occasional travel of up to 10% to Columbia SC office.
Previous experience in utilization management required.
Prior clinical experience preferably in an acute care, skilled nursing or rehabilitation clinical setting.
Comprehensive knowledge of Microsoft Word, Outlook and Excel.
Self-provided internet service with 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.
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.
BSN or Bachelor's degree in a related field.
Health Plan experience.
Previous Medicare/Medicaid Experience.
Call center or triage experience.
Bilingual.

Responsibilities

Utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations.
Interprets 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 goals, including their linkages to related areas.
Follows established guidelines/procedures.