Utilization Management Nurse

Humana • Work at Home - Florida, FL

1d • $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, 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. 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

• Licensed Registered Nurse (RN) with at least 3 years prior clinical experience in an acute care, skilled, long term care or rehabilitation setting
• Licensed Practical Nurse (LPN) with at least 5 years of clinical experience in acute care, skilled, long term care or rehabilitation setting.
• MUST reside in the state of FLORIDA
• License in the state of Florida with no disciplinary action
• Ability to work independently under general instructions and with a team.

Nice To Haves

• BSN or Bachelors degree in a related field
• Prior experience in utilization management/review and or prior authorizations.
• Background in case management for Long-Term Services and Supports (LTSS) members.
• Experience with MCG guidelines
• Experience evaluating requests for durable medical equipment.
• Familiarity with health plan operations.

Responsibilities

• Utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or 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.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Follows established guidelines/procedures.

Benefits

• medical
• dental
• 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 and long-term disability
• life insurance

What This Job Offers

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