The Utilization Management Compliance Nurse 2 ensures mandatory reporting is completed. Conducts and summarizes compliance audits.
Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals.
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.
Active Unrestricted RN license in the state of KY OR Compact RN License with the ability to be licensed in multiple states without restrictions
BSN or Equivalent Nursing Experience
A minimum of three years varied nursing experience
A minimum of two years Utilization Management experience utilizing MCG/Interqual Guidelines OR have a MCG Certification
Proficient with Microsoft Office products including Word, Excel and Outlook
This role is 40 hours a week Monday – Friday
This role may require travel to the Market Office for meetings and trainings
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.
Previous experience with compliance quality auditing.
Previous experience with NCQA Utilization Management regulations.
Health Plan experience working with large carriers
Previous Medicare/Medicaid experience a plus
Current MCG certification
Work At Home Requirements
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
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