Utilization Management Nurse

Humana Inc; Lansing (MI); Remote; USD 71,000 - 98,000; Full time

Job summary

A health services organization in Michigan is seeking a Utilization Management Nurse 2. The role involves coordinating care, interpreting clinical guidelines, and providing support in medical service documentation. Candidates must be a licensed RN with at least 3 years of clinical experience and strong communication skills. This position offers a competitive salary and various benefits, with an 8 am to 5 pm work schedule, Monday to Friday.

Benefits

Competitive 401k match

Generous Paid Time Off

Tuition Reimbursement

Health insurance benefits

Qualifications

• 3+ years of prior clinical experience as nurse in acute care setting.
• Comprehensive knowledge of Microsoft Office.
• Passionate about improving consumer experiences.

Responsibilities

• Coordinate communication with providers for optimal care.
• Interpret criteria to provide appropriate services.
• Make independent decisions regarding work methods.

Skills

Clinical nursing skills

Excellent communication skills

Critical thinking

Ability to work independently

Education

Licensed Registered Nurse (RN)

BSN or Bachelor's degree in a related field

Tools

Microsoft Word

Outlook

Excel

Job description

Overview

Become a part of our caring community and help us put health first

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. 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. 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.

Use your skills to make an impact

Responsibilities

Note: This section reflects the responsibilities described in the original text, organized for clarity.

• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Interpret criteria, policies, and procedures to provide appropriate treatment, care, or services for members.
• Make decisions regarding own work methods, occasionally in ambiguous situations, with minimal direction and guidance where needed.
• Follow established guidelines and procedures.

Required Qualifications

• Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action (Compact Licensure strongly preferred)

• 3+ years of prior clinical experience as nurse in acute care setting

• Comprehensive knowledge of Microsoft Word, Outlook and Excel

• Excellent communication skills both verbal and written

• 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

• Education: BSN or Bachelor's degree in a related field

• Health Plan experience

• Experience in utilization management or related activities reviewing criteria to ensure appropriateness of care preferred

• Previous Medicare experience a plus

• Milliman MCG experience preferred

Additional Information

• Hours for this role are: Monday-Friday 8am-5pm (Various Time Zones)

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• 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

Compensation and Benefits

• Scheduled Weekly Hours: 40

• Pay Range: $71,100 - $97,800 per year (base pay; geographic/location-based variations may apply). Eligible for bonus incentive plan based on company and/or individual performance.

• Benefits starting day 1 of employment

• Competitive 401k match

• Generous Paid Time Off accrual

• Tuition Reimbursement

• Parent Leave

• Go365 perks for well-being

Interview 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 from you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first round interview, you will receive an email correspondence inviting you to participate in a Modern Hire interview. In this interview, you will listen to a set of interview questions over your phone or text and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

#ThriveTogether #WorkAtHome

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.