Utilization Management Nurse 2 - Front End Review - Northeast Region

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

Creating Healthy Communities is good for the Soul. Join Us! 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

Coordinates and communicates with providers, members, or other parties to facilitate appropriate discharge planning including to assist with social determinants and closing gaps

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 Qualifications

Licensed Registered Nurse (RN) with no disciplinary action (New York license is required)

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

Must have good typing skills and proficiency using MS Office Word, Excel and Outlook

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

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

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

Active compact state RN license

Health Plan experience

Previous Medicare/Medicaid Experience a plus

Call center or triage experience

Previous experience in utilization management strongly preferred

Previous experience with Milliman (MCG)

Discharge planning and/or home health or rehab

Scheduled Weekly Hours

40

Company info

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