Overview 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 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The role uses clinical knowledge, communication skills, and independent critical thinking to interpret 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 guidance where needed. Follows established guidelines/procedures.
Responsibilities Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
Interpret criteria, policies, and procedures to determine appropriate care or services for members.
Make decisions regarding own work methods, occasionally in ambiguous situations, with minimal direction and guidance as needed.
adhere to established guidelines and procedures.
Required Qualifications Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action.
MUST have Compact License
Greater than one year of clinical experience in an RN role in an acute care setting with preference for specialty areas such as critical care, emergency room, trauma units, etc.
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 Education: BSN or Bachelor's degree in a related field
Three or more years of clinical experience in an acute care setting with preference for specialty areas such as critical care, emergency room, trauma units, etc.
Experience as an MDS Coordinator or discharge planner in an acute care setting
Previous experience in utilization management/utilization review for a health plan or acute care setting
Compact license PLUS a single state RN Licensure in any of the following non-compact states: California, Hawaii, Nevada, Oregon
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Call center or triage experience
Bilingual is a plus
Additional Information Scheduled Weekly Hours: 40
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Work-At-Home Requirements Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role).
A minimum standard speed of 25 Mbps download x 10 Mbps upload is required for optimal performance.
Check your internet speed at www.speedtest.net
A dedicated office space lacking ongoing interruptions to meet productivity requirements and to protect member PHI / HIPAA information.
Pay and Benefits Salary: $71,100 - $97,800 per year. The compensation range reflects a good faith estimate of starting base pay for full-time (40 hours per week) employment at the time of posting. Pay may be higher or lower based on geographic location and demonstrated job-related skills, knowledge, experience, education, certifications, etc.
Description of Benefits: Humana offers competitive benefits that support whole-person well-being, including medical, dental and vision benefits, 401(k), paid time off, holidays, voluntary time off, paid parental and caregiver leave, disability coverage, life insurance, and other opportunities.
About Us About OneHome: OneHome coordinates a full range of post-acute care ranging from home health, infusion therapy and durable medical equipment services at patients’ homes. OneHome’s patient-focused model creates one integrated point of accountability that coordinates with physicians, hospitals and health plans serving more than one million health plan members nationwide. OneHome was acquired by Humana in 2021 to advance value-based care. Our culture is inclusive, diverse, and caring.
About Humana: Humana Inc. is committed to putting health first – for our teammates, our customers, and our company. Through Humana insurance services, and CenterWell healthcare services, we make it easier for millions to achieve their best health.
Equal Opportunity Employer It is Humana’s policy 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. Humana provides free language interpreter services. See our accessibility resources page for more information.