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DescriptionThe 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.ResponsibilitiesThe 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 QualificationsLicensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action
3-5 years of Nursing experience required
Prior clinical experience preferably in an acute care hospital, skilled or rehabilitation clinical setting
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Excellent communication skills both verbal and written
Ability to work independently under general instructions and with a team
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred QualificationsEducation: BSN or Bachelor's degree in a related field
Utilization management experience or related activities reviewing criteria to ensure appropriateness of care is strongly preferred
Health Plan experience
Previous Medicare experience a plus
Milliman MCG experience preferred
Work-At-Home RequirementsWAH 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 InformationHours for this Weekend role are: Thursday-Sunday, 6am-5pm EST (4 day 10 hour shift)
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 Hours40
Full-time