• 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 will have respectful conversations and maintain curiosity around new ways of doing business and new opportunities to further support our members and our business unit needs.
• The Utilization Management Nurse 2 will understand that healthcare business continues past the end of a business day and may require additional hours worked on any given day, week, weekend, or holiday.
• The Utilization Management Nurse 2 will have solution-oriented thinking and will promote high quality work while improving processes to promote simplicity.

Responsibilities

The Telephonic 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
• Coordinates and communicates with providers, members, or other parties to facilitate appropriate discharge planning including to assist with social determinants and closing gaps
• 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

• Active RN license in the state(s) in which the nurse is required to practice
• Prior acute care clinical experience (3-5 years of experience working in any of the following areas: ER, Critical Care, ICU, Ortho, Med Surg or Tele)
• Must have good typing skills and proficiency using MS Office Word, Excel and Outlook
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Ability to work independently under general instructions and with a team
• Mountain or Pacific Time zone residency

Preferred Qualifications

• Bachelor’s degree in nursing (BSN)
• Health Plan experience
• Previous Medicare experience a plus
• Previous experience with MCG
• Previous experience in utilization management or related activities reviewing criteria to ensure appropriateness of care

Work-At-Home Requirements

• WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense
• A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required
• Satellite and Wireless Internet service is NOT allowed for this role
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information

• Hours for this role are: Monday-Friday 8am-5pm
• Must live within Mountain or Pacific Time Zone

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Scheduled Weekly Hours