Utilization Management Review Nurse

About the role

The Utilization Management Nurse 2 works in a supportive, caring community at Humana, focusing on coordinating, documenting, and communicating medical services and benefit administration determinations. They utilize clinical nursing skills to interpret criteria, policies, and procedures to ensure the best and most appropriate treatment, care, or services for members.

Responsibilities

• Interprets 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.
• Makes decisions regarding own work methods and requires minimal direction.
• Fulfills department, segment, and organizational strategy.

Requirements

• Licensed Registered Nurse (RN) in the state of Ohio with no disciplinary action.
• At least 3 years of Medical Surgery, Heart, Lung, or Critical Care Nursing experience.
• Previous experience in utilization management.
• Prior clinical experience preferably in an acute care, skilled, or rehabilitation clinical setting.
• Passionate about contributing to an organization focused on continuously improving consumer experiences.

Preferred Qualifications

• Bachelor's Degree.
• 3 or more years experience in a high volume community or mail order pharmacy practice environment.
• Health Plan experience.
• Previous Medicare/Medicaid Experience.
• Call center or triage experience.
• Bilingual.

Work at Home Requirements

• Self-provided internet service must meet minimum download speed of 25 Mbps and upload speed of 10 Mbps.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel

• Occasional travel to Humana's offices for training or meetings may be required.

Benefits

• 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.
• Many other opportunities.

About Us

Humana Inc. is a leading U.S. healthcare company offering competitive benefits that support whole-person well-being. 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. Our efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large.