Become a part of our caring community and help us put health first

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 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

Daily Activities:

• Reconciling census and updating existing cases as needed.
• Reviewing clinical information on all new admissions and making utilization determinations in accordance with Humana senior products UM policies. Facilitating the transition of care.
• Reviewing clinical information for the appropriateness as compared to MCG; Communicating case status to the facility as needed.
• Facilitating discharge planning and transition of care processes through outreach to the member and collaboration with the member’s health care team to maximize the member’s benefits and resources. This includes case management referrals and any other specific market initiatives.
• Performing concurrent review and/or discharge planning for all Humana Medicare/Medicaid hospitalized members
• Updating UM cases as needed (e.g., diagnosis, notes, discharge tools, discharge dates and dispositions) and in accordance with Humana senior products policies and procedures.
• Assisting/educating facility staff regarding Humana’s processes for prior authorization, etc.

Use your skills to make an impact

Required Qualifications

• Licensed Registered Nurse (RN) compact licensure with no disciplinary action
• 3+ years of prior Acute Care clinical experience
• 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

Preferred Qualifications

• Bachelor's degree in nursing (BSN)
• Experience in Utilization Management is strongly preferred
• Health Plan experience
• Previous Medicare experience a plus
• Milliman MCG experience preferred

Work-At-Home Requirements

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

Additional Information

• Hour are Monday-Friday 8:00am-5:00pm EST/CST
• This is a remote position

Scheduled Weekly Hours

40

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana 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 because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.