The Utilization Management Behavioral Health Professional 2 – Registered Nurse completes telephonic reviews with the Utilization Reviewer at the Behavioral Health Facilities to obtain sufficient clinical information. The Utilization Management Behavioral Health Professional 2 uses clinical knowledge and independent critical thinking skills to apply the appropriate criteria to make a medical necessity determination.
Complete telephonic, faxed, and voicemail reviews with facilities
Assess discharge plans
Coordinated with Care Coordination and Case Management
Discuss cases with Medical Directors in daily rounds
Complete documentation for Quality Reviews for Peer Reviews
Department hours are 8-7:30 p.m. EST, shifts are based on business need and can change at any time
Associates Degree in Nursing
Must be licensed in a Compact State
Registered Nurse (RN)
Minimum of five (5) years of post-degree clinical experience in direct patient care
Three (3) years or more of Behavioral Health experience
Minimum of three (1) year of utilization management experience or knowledge of the UM process
Proficiency with Microsoft Office products
Proficient working with computers
WAH 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 25×10 (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
Experience with utilization review process
Knowledge of community health and social service agencies and additional community resources
Bilingual (English/Spanish); speaking, reading, writing, interpreting and explaining documents in Spanish
Prefer CA or AZ nursing license (must obtain license within 6 months of hire.)
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 or computer 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.
Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana’s secure website.
Scheduled Weekly Hours