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

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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, MDs, and administrative staff to facilitate optimal care and treatment
• Review UM inpatient admission and clinical information to determine appropriate level of care in a fast-paced environment
• Understands resources and role responsibilities as well as reporting structure
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
• Follows established guidelines/procedures to ensure all work is compliant with CMS and NCQA requirements
• Promotes collaboration within own team as well as others

Required Qualifications

• Licensed Registered Nurse (RN) in the appropriate state(s), with no disciplinary action
• 2 or more years of acute care nursing experience
• Comprehensive knowledge of 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

Preferred Qualifications

• Bachelor's degree in nursing (BSN)
• Utilization Management experience highly preferred
• MCG/Milliman experience
• Health Plan experience
• Previous Medicare Experience

Work-At-Home Requirements

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense
• Humana will provide Home or Hybrid Home/Office associates 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

Additional Information

• Hours are: Monday-Friday 10am-7pm EST

Scheduled Weekly Hours

40