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Clinical Utilization Management Nurse
2 months ago
Contribute to a Health-Focused Community
The Utilization Management Nurse 2 employs advanced clinical nursing expertise to enhance the coordination, documentation, and communication of medical services and benefit administration decisions. The responsibilities of the Utilization Management Nurse 2 are diverse and often necessitate the interpretation and independent assessment of suitable actions.
Fostering Healthy Communities is Our Mission The Utilization Management Nurse 2 applies clinical knowledge, effective communication, and critical thinking skills to interpret guidelines, policies, and procedures, ensuring the delivery of optimal treatment, care, or services for members.
- Facilitates and communicates with healthcare providers, members, and other stakeholders to ensure optimal care and treatment.
- Assists in discharge planning by coordinating with providers and members, addressing social determinants and closing care gaps.
- Understands the strategic objectives of the department and organization, including their interconnections with related areas.
- Makes informed decisions regarding work methods, often in ambiguous situations, requiring minimal supervision while seeking guidance as necessary.
- Adheres to established protocols and procedures.
Utilize Your Skills for Meaningful Impact
Essential Qualifications
- Active Registered Nurse (RN) Compact license with no disciplinary actions.
- Minimum of 3 years of diverse clinical nursing experience.
- Experience in utilization management, including familiarity with MCG/Milliman or Interqual guidelines.
- Prior clinical experience in acute care, hospital, skilled nursing, or rehabilitation settings is preferred.
- Proficient in Microsoft Word, Outlook, and Excel.
- Ability to work independently under general guidance and collaboratively within a team.
- Passionate about enhancing consumer experiences within a healthcare organization.
Desirable Qualifications
- Bachelor’s degree in nursing (BSN).
- Certification in Case Management (CCM).
- Experience in a health plan environment.
- Previous experience with Medicare/Medicaid.
- Background in call center or triage operations.
Remote Work Requirements
To ensure effective performance for remote or hybrid associates, the self-provided internet service must meet the following criteria:
- A minimum download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; a wired cable or DSL connection is preferred.
- Satellite, cellular, and microwave connections may only be used with prior approval from leadership.
- Associates working from home in specific states will receive bi-weekly compensation for internet expenses.
- Humana will supply necessary telephone equipment to meet business requirements.
- Work from a designated area free from ongoing interruptions to safeguard member PHI / HIPAA information.
Additional Information
- Standard working hours are Monday to Friday, 8 AM to 5 PM CST, with potential overtime or weekend work based on business needs.
- This position is remote.
Scheduled Weekly Hours
40
Compensation 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 vary based on geographic location and individual qualifications: $69,800 - $96,200 per year. This position is eligible for a bonus incentive plan based on company and/or individual performance.
Benefits Overview
Humana, Inc. and its affiliated subsidiaries offer competitive benefits that promote holistic well-being. Associate benefits are designed to support personal wellness and informed healthcare decisions for you and your family, recognizing that life extends beyond work. Benefits include medical, dental, and vision coverage, a 401(k) retirement savings plan, paid time off (including personal holidays, volunteer time off, and paid parental leave), short-term and long-term disability, life insurance, and numerous other opportunities.
About Humana
Humana Inc. is dedicated to prioritizing health for our teammates, customers, and the organization. Through our insurance services and healthcare offerings, we strive to facilitate the best health outcomes for the millions we serve, providing the necessary care and services at the right time. Our efforts contribute to improved quality of life for individuals across various demographics.
Equal Opportunity Commitment
Humana is committed to ensuring equal employment opportunities for all employees and applicants, prohibiting discrimination based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or veteran status. We actively take steps to employ and advance individuals based on valid job requirements.
Humana adheres to all applicable federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion. We also provide free language interpreter services.
