Utilization Management RN (Discharge & Auth) Weekends Required

Humana • Louisville, KY

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/or benefit administration determinations for Humana’s Kentucky Medicaid Plan. This role has primary responsibility for performing medical necessity reviews, including initial and concurrent authorization decisions, using established clinical criteria and independent clinical judgment. The Utilization Management Nurse 2 also plays a key role 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 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. Maintain compliance with state regulations and organizational standards for coordinated member discharge, ensuring all plans are documented and communicated effectively. Perform initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions. Engage providers via telephonic, virtual, and onsite collaboration as needed. Follows established guidelines/procedures.

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.

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. A Language Proficiency Assessment will be conducted to evaluate fluency in reading, writing, and speaking in both languages prior to assignment to a dedicated member service line.

Responsibilities

• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Maintain compliance with state regulations and organizational standards for coordinated member discharge, ensuring all plans are documented and communicated effectively.
• Perform initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions.
• Engage providers via telephonic, virtual, and onsite collaboration as needed.
• 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

What This Job Offers

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