Utilization Management Nurse 2
The Utilization Management Nurse applies a Person-Centered approach, works within specific guidelines and procedures; applies advanced technical knowledge and clinical criteria to solve moderately complex problems.
Responsibilities
- Use clinical knowledge, communication skills, and independent critical thinking to interpret criteria, policies, and procedures for the best treatment, care, or services.
- Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
- Understand department, segment, and organizational strategy and operating objectives.
- Make decisions regarding own work methods, occasionally in ambiguous situations.
- Follow established guidelines/procedures.
Essential Functions and Responsibilities
- Perform complex clinical reviews to support Utilization decisions and support claims processes.
- Understand and apply standard utilization management criteria including MCG and/or Interqual.
- Document clinical reviews, application of clinical criteria, and decisions clearly using standard tools and clinical documentation systems.
- Follow utilization management policies and procedures for compliance with state and federal requirements.
- Collaborate with internal departments, providers, and community partners for high-quality utilization management services.
- Complete education and self-development activities per Humana Healthy Horizons and department requirements.
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences.
Required Qualifications
- Licensed Registered Nurse, RN, in the state of Oklahoma without restrictions or disciplinary actions.
- Minimum 3 years of Medical Surgery, Heart, Lung, Emergency Room, or Critical Care Nursing experience required.
- Working knowledge of MS Office including Word, Excel, PowePoint, and Teams in a Windows-based environment.
- Ability to work independently under general instructions and with a team.
Additional Requirements/Adherence
- Workstyle: Remote work at home.
- Preferred Location: Oklahoma. Alternate Locations: United States.
- Training Schedule: Must be able to attend training schedule. Monday – Friday; 8:00am – 5:00pm Central Time.
- Schedule: Must be able to work a 40-hour work week, Monday through Friday, 8:00 AM to 5:00 PM Central Time.
- Over-time and weekends may be requested to meet business needs. Leader will discuss during interview.
- Travel: Must be willing to commute about 5-10% to meet with providers or staff meetings. More information will be provided during the interview.
Work at Home Guidance
- Must have accessibility to hardwired high-speed internet with minimum speeds of 25Mx10M for a home office (Wireless and Satellite are prohibited).
- 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.
Preferred Qualifications
- Bachelor’s degree.
- Managed Care / Health Plan experience.
- Previous Medicare/Medicaid Experience.
- Bilingual preferred.
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab.
- Experience working with MCG or Interqual guidelines.
- Working knowledge using the following systems/platforms CGX, MHK, Maccess, CAS.
Additional Information
Interview Format: As part of our hiring process for this opportunity, we will be using an exciting screening and interviewing technology called Modern Hire to enhance our hiring and decision-making ability…
SSN Alert: Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number…
Humana offers a variety of benefits…
#L1-Remote
Scheduled Weekly Hours: 40
Not Specified 0′
Apply Now