Utilization Management Registered Nurse

Humana

4d • Remote

About The Position

Become a part of our caring community and help us put health first 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. Role Overview: 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. Medical necessity reviews for Medicaid claims and Provider disputes. Must be passionate about contributing to an organization focused on continuously improving consumer experiences Use your skills to make an impact

Requirements

• Active unrestricted Compact Registered Nurse, (eNLC) license (RN) with no disciplinary action in the state that you reside, with the ability to obtain multiple state registered nurse license
• At least three (3) years of clinical nursing experience, ideally within acute care, skilled nursing, or rehabilitation settings. This should include experience in areas such as medical-surgical, cardiology, pulmonology, maternity/obstetrics, or critical care nursing.
• Intermediate to advanced knowledge of Microsoft Word, Outlook and Excel, systems and platforms
• Ability to work independently under general instructions and with a team
• To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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 required. · Satellite, cellular and microwave connection can be used only if approved by leadership. · Humana will provide Home or Hybrid Home/Office employees 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.

Nice To Haves

• Bachelor's degree
• Previous experience in prior authorization, claims, provider disputes and/or utilization management in healthcare, health insurance, evaluating medical necessity and appropriateness of care
• Health Plan/MCO experience
• Previous Medicare/Medicaid Experience a plus

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.
• Medical necessity reviews for Medicaid claims and Provider disputes.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Benefits

• Humana provides medical, dental and 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 and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees