Utilization Management RN (Discharge & Auth)
About The Position
The Utilization Management Nurse 2 uses clinical nursing skills to support the coordination, documentation and communication of medical services and benefit administration determinations for Humana's Kentucky Medicaid Plan. You will perform medical necessity reviews, including initial and concurrent authorization decisions, using established clinical criteria and independent clinical judgment. The Utilization Management Nurse 2 also meaningfully contributes in facilitating comprehensive, proactive, and barrier-focused discharge planning to home or a lower level of care. The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills. These skills are used towards interpreting criteria, policies, and procedures. The goal is to provide the best and most appropriate treatment, care, or services for members. Coordinate and communicate with providers, members, or other parties to facilitate care and treatment. Collaborate with members, their families, and care providers to develop individualized discharge plans that address clinical needs and promote continuity of care, whether virtually or in-person. Maintain compliance with state regulations and organizational standards for coordinated member discharge, ensuring that you document all plans. Perform initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions. Engage providers by telephonic, virtual, and onsite collaboration. Lead in-depth discharge planning and ensure post-discharge resources are in place Follow established guidelines/procedures. Use your skills to make an impact.
Requirements
- Licensed Registered Nurse (RN) in the state of Kentucky, in good standing with no disciplinary action.
- 1+ year of utilization management experience.
- Maintain compliance with state regulations and organizational standards, ensuring that we coordinate and document member discharge plans and communicate them.
- Experience performing initial and concurrent reviews for medical service requests, with the ability to interpret clinical criteria and apply judgment to support appropriate use and benefit administration.
- Experience engaging with providers and care teams through telephonic, virtual, or onsite interactions to facilitate authorizations and support member-centered discharge planning.
- Strong proficiency in Microsoft Office Suite, including Word, Excel, and PowerPoint.
- Valid state driver's license and expected to maintain personal vehicle liability insurance.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Nice To Haves
- 2+ years of progressive clinical experience in an acute care, skilled nursing, or rehabilitation setting.
- Bachelor's degree in nursing.
- MCG experience.
- Experience in discharge planning, transitions of care, and familiarity with community-based resources and social determinants of health.
- Health plan experience.
- Medicaid experience.
- Bilingual in English and another language.
Responsibilities
- Coordinate and communicate with providers, members, or other parties to facilitate care and treatment.
- Collaborate with members, their families, and care providers to develop individualized discharge plans that address clinical needs and promote continuity of care, whether virtually or in-person.
- Maintain compliance with state regulations and organizational standards for coordinated member discharge, ensuring that you document all plans.
- Perform initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions.
- Engage providers by telephonic, virtual, and onsite collaboration.
- Lead in-depth discharge planning and ensure post-discharge resources are in place.
- Follow established guidelines/procedures.
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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
