Telephonic Utilization Management Nurse - Acute Care - Remote Tennessee

Profile

Description

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.

Responsibilities

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 and receives guidance where needed.

Follows established guidelines/procedures.

Daily Activities:

Reconciling census and updating existing cases as needed.

Reviewing clinical information on all new admissions and making utilization determinations in accordance with Humana senior products UM policies. Facilitating the transition to alternate level of care.

Reviewing clinical information for the appropriateness of the level of care (e.g., observation versus inpatient status). Communicating case status to the facility as needed.

Facilitating discharge planning and transition of care processes through face-to-face member interaction and collaboration with the member's health care team to maximize the member's benefits and resources. This includes case management referrals and any other specific market initiatives.

Performing concurrent review and/or discharge planning for all Humana Medicare/Medicaid hospitalized members

Updating UM cases as needed (e.g., diagnosis, notes, discharge tools, discharge dates and dispositions) and in accordance with Humana senior products policies and procedures.

Assisting/educating facility staff regarding Humana's processes for prior authorization, observation status, etc.

Required Qualifications

Unrestricted Licensed Registered Nurse (RN) in TN with no current disciplinary action

Must be willing to obtain a compact RN license if offered the position

3-5 years of Medical Surgery, Heart, Lung or Critical Care Nursing experience required

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Ability to work independently under general instructions and with a team

Must be available to work Monday - Friday 8:00 AM - 5:00 PM

Additional Requirements to Work At Home

Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work.

Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.

Preferred Qualifications

Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting

Previous Utilization Management experience 1-3 year preferred

Education: BSN or Bachelor's degree in a related field

Health Plan experience

Previous Medicare/Medicaid Experience a plus

Additional Information

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com