RN - Telephonic Utilization Management Nurse- Medicare- Remote - Southeast Region at Humana

About the position The Utilization Management Nurse 2 plays a crucial role in the healthcare system by utilizing clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. This position requires a blend of clinical knowledge, communication skills, and independent critical thinking to interpret criteria, policies, and procedures, ensuring that members receive the best and most appropriate treatment, care, or services. The nurse will coordinate and communicate with providers, members, and other parties to facilitate optimal care and treatment, as well as assist with appropriate discharge planning, addressing social determinants, and closing care gaps. In this role, the nurse will be expected to understand the department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Utilization Management Nurse 2 will make decisions regarding their work methods, often in ambiguous situations, requiring minimal direction while receiving guidance when necessary. Following established guidelines and procedures is essential to ensure compliance and quality of care. This position is not only about clinical expertise but also about making a positive impact on the community by contributing to an organization focused on continuously improving consumer experiences. The nurse will work from home, requiring a reliable internet connection and a dedicated workspace to protect member PHI and HIPAA information. Responsibilities • Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. , • Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. , • Assist with appropriate discharge planning, including addressing social determinants and closing care gaps. , • Interpret criteria, policies, and procedures to provide the best treatment and care for members. , • Make independent decisions regarding work methods in ambiguous situations with minimal direction. , • Follow established guidelines and procedures to ensure compliance and quality of care. Requirements • Licensed Registered Nurse (RN) with compact license and no disciplinary action. , • 3 - 5 years of clinical nursing experience, preferably in Emergency room or critical care. , • Prior clinical experience in an acute care, skilled, or rehabilitation clinical setting. , • Comprehensive knowledge of Microsoft Word, Outlook, and Excel. , • Ability to work independently under general instructions and collaboratively with a team. , • Must provide a high-speed DSL or cable modem for a home office with a minimum standard speed of 10x1 (10mbs download x 1mbs upload). , • Passionate about contributing to an organization focused on improving consumer experiences. Nice-to-haves • BSN or Bachelor's degree in a related field. , • Health Plan experience. , • Experience in utilization management or related activities reviewing criteria to ensure appropriateness of care. , • Previous Medicare experience. , • Milliman MCG experience. Benefits • Medical, dental, and vision benefits. , • 401(k) retirement savings plan. , • Paid time off, including company and personal holidays, volunteer time off, paid parental and caregiver leave. , • Short-term and long-term disability insurance. , • Life insurance. , • Opportunities for personal wellness and smart healthcare decisions. Apply Job!