Utilization Management Nurse – Mid-West Region

Description 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 Creating Healthy Communities is good for the Soul. Join Us! 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 3-5 years of acute care nursing experience Prior clinical experience preferably in an acute care, hospital, skilled or rehabilitation clinical setting 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 Schedule and Hours are: Monday through Friday 10am-7pm EST #LI-Remote Scheduled Weekly Hours 40