Utilization Management Nurse 2

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. Reports to the UM Nurse, Manager

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.

Required Qualifications

• Licensed Registered Nurse (RN) with at least 3 years prior clinical experience in an acute care, skilled, long term care or rehabilitation setting
• Licensed Practical Nurse (LPN) with at least 5 years of clinical experience in acute care, skilled, long term care or rehabilitation setting.
• MUST reside in the state of FLORIDA
• License in the state of Florida with no disciplinary action

Preferred Qualifications

• BSN or Bachelors degree in a related field
• Prior experience in utilization management/review and or prior authorizations.
• Background in case management for Long-Term Services and Supports (LTSS) members.
• Experience with MCG guidelines
• Experience evaluating requests for durable medical equipment.
• Familiarity with health plan operations.

Additional Information

• Must work an 8 hour shift between 8:30AM-5:30PM local time Monday-Friday

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

$71,100 - $97,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.