Clinical Utilization Nurse

2 weeks ago

GondrecourtleChâteau, Grand Est, United States Humana Full time

Join our dedicated team and prioritize health and wellness

The Clinical Utilization Nurse plays a crucial role in utilizing nursing expertise to enhance the coordination, documentation, and communication of medical services and benefit administration decisions. The responsibilities of the Clinical Utilization Nurse are diverse and often necessitate the interpretation and independent judgment regarding the best courses of action.

This position requires the application of clinical knowledge, effective communication skills, and independent critical thinking to interpret guidelines, policies, and procedures, ensuring optimal treatment, care, or services for members.

  • Facilitates communication and coordination with healthcare providers, members, and other stakeholders to ensure the highest quality of care. Understands the strategic objectives and operational goals of the department and organization, including their interconnections with related areas.
  • Exercises independent judgment in determining work methods, even in uncertain situations, while requiring minimal supervision and guidance as necessary.
  • Adheres to established protocols and procedures.

Key Responsibilities:

  • Updating case information and reconciling census as necessary.
  • Evaluating clinical data for all new admissions and making utilization decisions in line with organizational policies. Assisting in the transition to alternative care levels.
  • Assessing clinical information to determine the appropriateness of care levels (e.g., observation vs. inpatient status) and communicating case updates to facilities as required.
  • Supporting discharge planning and care transition processes through outreach to members and collaboration with their healthcare teams to maximize benefits and resources. This includes referrals for case management and other specific initiatives.
  • Conducting concurrent reviews and/or discharge planning for all hospitalized members under the organization's Medicare/Medicaid programs.
  • Updating utilization management cases as necessary (e.g., diagnosis, notes, discharge tools, discharge dates, and outcomes) in accordance with organizational policies and procedures.
  • Providing education and assistance to facility staff regarding the organization's processes for prior authorization, observation status, and more.

Utilize your expertise to make a difference

Essential Qualifications

  • Active Registered Nurse (RN) license with no disciplinary actions
  • Minimum of 3 years of experience in acute care settings
  • Proficient in Microsoft Word, Outlook, and Excel
  • Ability to work autonomously under general direction and collaboratively within a team
  • A strong commitment to enhancing consumer experiences within the organization

Preferred Qualifications

  • Bachelor’s degree in nursing (BSN)
  • Prior experience in utilization management or related activities reviewing care appropriateness is highly desirable
  • Experience in health plan operations
  • Previous exposure to Medicare processes is advantageous
  • Familiarity with Milliman MCG guidelines is preferred

Remote Work Requirements

To ensure effective performance for remote or hybrid associates, the following internet service criteria must be met:

  • 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 residing and working from specific states will receive bi-weekly payments for internet expenses
  • The organization will provide necessary telephone equipment to meet business requirements
  • Work must be conducted from a dedicated space free from interruptions to protect member information

Additional Information

  • Standard hours are Monday-Friday, 8:00 AM - 5:00 PM EST/CST
  • This position is remote

Scheduled Weekly Hours

40

Compensation Range

The salary range provided reflects a good faith estimate of starting base pay for full-time employment. The actual pay may vary based on geographic location and individual qualifications, including skills, knowledge, experience, and education. The range is $69,800 - $96,200 per year, and this position is eligible for a bonus incentive plan based on performance.

Benefits Overview

The organization offers a comprehensive benefits package that supports overall well-being. Benefits are designed to promote personal health 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, short-term and long-term disability, life insurance, and numerous other opportunities.

About Us

The organization is dedicated to prioritizing health for our team members, customers, and the community. Through our insurance services and healthcare offerings, we strive to make it easier for the millions we serve to achieve optimal health, delivering necessary care and services when they are needed. Our efforts contribute to improved quality of life for individuals across various programs.

Equal Opportunity Employer

The organization maintains a policy of non-discrimination in employment practices based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or veteran status. We are committed to affirmative action to employ and advance all individuals based on valid job requirements.

The organization complies with 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.

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