Utilization Management Nurse

Humana; United (LA); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off

Job summary

Humana is seeking a Utilization Management Nurse to support the coordination, documentation and communication of medical services and benefit determinations. This role requires clinical nursing skills and independent decision-making.

You will interpret criteria and policies, coordinate with providers and members to ensure appropriate care, and work remotely within the eastern or central time zones.

Qualifications

• Licensed Registered Nurse (RN) with no disciplinary action.
• Bachelor's degree
• 3 - 5 years of Medical Surgery, Heart, Lung or Critical Care Nursing experience
• Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
• Comprehensive knowledge of Microsoft Word, Outlook and Excel
• Ability to work independently under general instructions and with a team
• MCG/InterQual experience
• Previous experience in utilization management
• Health Plan experience
• Previous Medicare/Medicaid experience
• Call center or triage experience

Responsibilities

• Coordinate and communicates with providers, members, or other parties to facilitate optimal care and treatment.
• Interpret criteria, policies, and procedures to provide the best and most appropriate treatment, care or services.
• Follows established guidelines/procedures and works both independently and within a team.

Job description

The Utilization Management Nurse utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Utilization Management Nurse utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. 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, 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 Qualifications

• Licensed Registered Nurse (RN) (Compaq License) with no disciplinary action.
• Bachelor's degree
• 3 - 5 years of Medical Surgery, Heart, Lung or Critical Care Nursing experience
• Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
• Comprehensive knowledge of Microsoft Word, Outlook and Excel
• Ability to work independently under general instructions and with a team

Preferred Qualifications

• MCG/InterQual experience
• Previous experience in utilization management
• Health Plan experience
• Previous Medicare/Medicaid experience
• Call center or triage experience

Additional Information

Remote to work the eastern or central time zone

Work at Home Requirements: 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 required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

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

Florida Background Screening Requirements: Notice for candidates applying to this position from a Florida work location, including Florida home-based work location. This position is subject to Florida Level 2 background screening through the Care Provider Background Screening Clearinghouse. For information about the screening process and requirements, visit: https://info.flclearinghouse.com.

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 year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

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.