Utilization Management Nurse

Humana • Indianapolis, SC

1d • Remote

About The Position

The Utilization Management Nurse uses clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. The Utilization Management Nurse's work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Utilization Management Nurse uses clinical knowledge to interpret criteria and procedures to provide the best treatment, care, or services for members. They coordinate and communicate with providers to facilitate optimal care and treatment. This role requires understanding department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The nurse makes decisions regarding their own work methods, occasionally in ambiguous situations, and receives guidance where needed, while following established guidelines/procedures.

Requirements

• Active licensed Registered Nurse (RN) in the state of Virginia or obtain a multi-state license in a state that participates in the enhanced licensure (eNLC) with no disciplinary action.
• At least 2 years prior utilization management experience preferably in an acute care skilled or rehabilitation clinical or health plan/hospital setting.
• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint.
• Proficiency navigating multiple systems and platforms.
• Ability to troubleshoot and resolve basic technical difficulties in a remote environment.
• Ability to work independently under general instructions and with a team.
• Strong oral, written, and interpersonal communication skills.
• Problem-solving skills.
• Facilitation skills.

Nice To Haves

• BSN degree
• Experience with MCG/InterQual
• Health Plan experience
• Medicare/Medicaid experience

Responsibilities

• Use clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations.
• Interpret criteria and procedures to provide the best treatment, care, or services for members.
• Coordinate and communicate with providers to facilitate optimal care and treatment.
• Understand department, segment, and organizational strategy and operating objectives.
• Make decisions regarding own work methods, occasionally in ambiguous situations, and receive guidance where needed.
• Follow established guidelines/procedures.

Benefits

• Medical benefits
• Dental benefits
• Vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• Short-term disability
• Long-term disability
• Life insurance

What This Job Offers

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