Utilization Management Registered Nurse, RN
DescriptionThe 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.
Registered Nurse (RN) in the state of Florida without restriction and ability to be licensed in multiple states without disciplinary action
3-5 years acute care, (Medical Surgical, Heart, Lung or Critical Care), skilled or rehabilitation nursing experience
Previous hospital or health plan utilization management
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Ability to work independently under general instructions and with a team
Additional Requirements / Adherence:
Workstyle: Remote work at home
Alternate Locations: U.S.
Travel: Occasional travel as needed to support business needs
Monday through Friday 8:00 AM - 5:00 PM Central or Eastern Time with weekend and holiday rotation.
Alternative work hours (4, 10-hour shifts or other may be possible). This will be discussed with the manager if selected for interview
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
Tuberculosis (TB) screening: This role is considered patient-facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be tested for TB.
Level II; AHCA background Associate working in the State of Florida will need Completion of a Level II; AHCA background clearance Fingerprinting.
Education: BSN or Bachelor's degree in a related field
Knowledge of MCG
Health Plan experience
Previous Medicaid Experience a plus
Bilingual is a plus - Language Proficiency Assessment will be performed to test fluency in reading, writing and speaking in both languages.
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Modern Hire Voice 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 (please be sure to check your spam or junk folders often to ensure communication isn’t missed) inviting you to participate in a Modern Hire Voice interview. In this interview, you will listen to a set of interview questions over your phone, 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.
This is a remote position
Scheduled Weekly Hours40