Utilization Management Nurse 2

Profile

Description

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.

Responsibilities

Location: work at home anywhere, Compact state RN licensed required

The Utilization Management Nurse 2 reviews the medical documentation, completes telephonic reviews with the Utilization Reviewer at the Acute Care Facilities to obtain sufficient clinical information. The Utilization Management Nurse 2 uses clinical knowledge and independent critical thinking skills to apply the appropriate criteria to make a medical necessity determination. The Utilization Management Nurse 2 will participate in initiatives which result in improved member outcomes, operational efficiencies, and process improvement opportunities.


Complete telephonic reviews with facilities
Assess discharge plans
Coordinated with Care Coordination and Case Management
Discuss cases with Medical Directors
Complete documentation for Quality Reviews for Peer Reviews
Hours for this role are M-F from 8-5 EST or CST


Required Qualifications


Associate's Degree
Registered Nurse license
Compact State license (must be licensed in the state you reside in)
3-5 years of clinical hospital setting experience
Minimum of 1 year of utilization management experience
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Ability to work independently under general instructions and with a team
Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required


Desired Qualifications


BSN
Appeal Review Experience
Knowledge of MCG (Milliam Care Guidelines)
Previous Managed Care/Medicare/Medicaid Experience a plus
Previous experience in utilization management a plus


Additional Information

Humana is an organization with careers that change lives - including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you're ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.

Scheduled Weekly Hours

40

Company info

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