Utilization Management Nurse

Become a part of our caring community. The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. Work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

About the role

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 while receiving guidance where needed.

Responsibilities

• Interpret criteria, policies, and procedures to provide appropriate treatment, care, or services for members.
• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Make independent determinations regarding work methods in ambiguous situations.

Requirements

• Licensed Registered Nurse (RN) with at least 3 years prior clinical experience in an acute care, skilled, long-term care, or rehabilitation setting, OR
• 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 and hold an active license in the state of Florida with no disciplinary action.
• Work an 8-hour shift between 8:30 AM - 5:30 PM local time, Monday-Friday.

Preferred Qualifications

• BSN or Bachelor's 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.

Work Environment

• This is a remote position with occasional travel to Humana's offices for training or meetings.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
• Self-provided internet service must meet the following criteria: minimum download speed of 25 Mbps and upload speed of 10 Mbps; wireless, wired cable, or DSL connection is suggested.

Pay

The pay range for this full-time (40 hours per week) position is $71,100 - $97,800 per year. This job is eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

Humana offers competitive benefits that support whole-person well-being, including:

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance.