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DescriptionThe 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.ResponsibilitiesThe 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.Required QualificationsLicensed Registered Nurse (RN) in a compact state with no disciplinary action. Must have valid compact license or reside in a compact state and be eligible to upgrade to compact licensure.
3 or more years of clinical experience
Proven ability to adapt to an ever-changing environment
Will consider qualified candidates without UM experience and/or Home Health clinical experience who have strong attention to detail, a diverse clinical background, ability to navigate through change, and a desire to learn utilization management.
Comprehensive knowledge of and experience with Microsoft Word, Outlook and Excel
Ability to work independently under general instructions and with a team
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Work-At-Home RequirementsWAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
Preferred QualificationsPrefer 2 to 3 years of home health experience and/or utilization management experience in a managed care setting
Health Plan experience
CGX experience
Additional InformationNurses must be willing to work rotational on call for weekends and holidaysTeam business hours cover 8am to 8pm EST with a 8 hour shift within these timeframesInterview Format :As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.If you are selected, you will receive correspondence inviting you to participate in a Modern Hire assessment. You will have a set of questions and you will provide responses to each question. You should anticipate this to take about 15 - 20 minutes. Your answers will be reviewed and you will subsequently be informed if you will be moving forward to next round.Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana's secure website.Vaccination PolicyHumana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.Scheduled Weekly Hours40
