Utilization Management Nurse

Humana Inc; Orlando (FL); Remote; USD 71,000 - 98,000; Full time

Job summary

Humana Inc. is looking for a Utilization Management Nurse to join their team in Florida. This role involves utilizing clinical nursing skills to coordinate care and ensure appropriate treatment for members. Candidates must have an RN license in Florida and at least three years of experience in an acute hospital setting. The position offers a fixed schedule from Saturday to Tuesday, with a competitive salary range and opportunities for bonuses based on performance.

Qualifications

• Must have at least three years of RN experience in an acute hospital setting.
• Proficient in Microsoft Office tools.
• Experience in utilization management preferred.

Responsibilities

• Utilizes clinical skills to coordinate and document medical services.
• Communicates with providers to facilitate optimal care.
• Performs reviews to determine medical necessity.

Skills

Clinical knowledge

Communication skills

Critical thinking

Education

RN license in Florida

BSN or Bachelor's degree in a related field

Tools

Microsoft Word

Microsoft Teams

Microsoft Outlook

Job description

Job Profile

Utilization Management Nurse 2

Job Level

Professional 2

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

Humana Healthy Horizons in Florida is seeking a Utilization Management Nurse (Front End Review) who will utilize clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse’s work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Fixed Schedule: Saturday through Tuesday, 7am-6pm Eastern Time Zone with occasional holiday coverage (2 holidays per year).

The Utilization Management Nurse:

• 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 or other parties to facilitate optimal care and treatment.
• Utilizes MCG criteria to perform acute concurrent initial reviews on Humana members to determine medical necessity.

Use your skills to make an impact

Required Qualifications

• Must reside and have an RN license in the State of Florida.
• Minimum of three (3) years’ RN experience in an acute hospital setting (medical surgery, cardiac, neuro, pulmonary, or critical care).
• Must be able to work Saturday through Tuesday, 7am – 6pm EST with 2 holidays per year.
• Proficient with Microsoft Word, Teams, and Outlook.

Preferred Qualifications

• One or more years of experience in utilization management.
• Previous Medicare/Medicaid Experience.
• Health plan experience.
• BSN or Bachelor's degree in a related field
• Bilingual (English/Spanish or English/Creole).
• Familiarity with Microsoft OneNote.

Additional Information

• Workstyle: Home. Home workstyle is defined as remote but will use Humana office space on an as needed basis for collaboration and other face-to-face needs.
• Work Location: must reside in Florida.
• Travel: less than 10%.
• Work days/hours: Saturday through Tuesday, 7am – 6pm EST with 2 holidays per year.

WAH Internet Statement

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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.
• Employees 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 employees 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.

HireVue

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue 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.

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

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$71,100 - $97,800 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Referral Bonus Information

This requisition is not eligible for a referral bonus.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

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.