Humana Looking For Utilization Management Registered Nurse, RN at Cincinnati, OH Full Time

The Utilization Management Nurse applies a Person-Centered approach, works within specific guidelines and procedures; applies advanced technical knowledge and clinical criteria to solve moderately complex problems.

Responsibilities

The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills to interpret 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. Requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Essential Functions and Responsibilities

Perform complex clinical reviews to gather clinical data to support Utilization Management decisions.

Understand and apply standard utilization management criteria including MCG and Interqual.

Document clinical reviews, application of clinical criteria and decisions clearly using standard tools and clinical documentation systems.

Follow utilization management policies and procedures to ensure compliance with state and federal requirements and incorporate industry best practices

Collaborate with internal departments, providers, and community partners to support the delivery of high-quality utilization management services

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Complete education and self-development activities per Humana Healthy Horizons and department requirements.

Required Qualifications

Licensed Registered Nurse, RN, in the state of Ohio without restrictions

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

Intermediate or better working knowledge using Microsoft Office Programs specifically Teams, Excel, PowerPoint, Outlook and Word, systems, platforms, and an ability to troubleshoot and resolve general technical difficulties

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

Additional Requirements/Adherence

Workstyle: Remote work at home

Location: Ohio, Kentucky, Indiana, Michigan, West Virginia

Hours: Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM Eastern Time, over-time may be requested to meet business needs.

Travel: Must be willing to commute about 5-10% for to meet with members. More information will be provided during the interview.

Work at Home Requirements:
Must have a separate room with a locked door that can be used as a home office to ensure absolute and continuous privacy during while you work

Must have accessibility to hardwired high speed internet with minimum speeds of 25Mx10M for a home office (Wireless and Satellite are prohibited)

Preferred Qualifications

Bachelor’s degree

Previous experience in Utilization Management using Interqual, Milliman or MCG

3-5 years of Medical/Surgical, Heart, Lung or Critical Care Nursing experience

Health Plan experience

Previous Medicare/Medicaid Experience

Bilingual preferred

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting screening and interviewing technology called Modern Hire to enhance our hiring and decision-making ability. We use this technology to gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

You will be able to respond to the recruiters preferred response method via text, video or voice technologies If you are selected for a screen, you may receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn’t missed) inviting you to participate. You should anticipate this screen to take about 15 to 30 minutes. Your recorded screen will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Covid Compliance Policy

For this job, associates are required to be fully COVID vaccinated, including booster or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.

If progressed to offer, you will be required to:
Provide proof of full vaccination, including booster or commit to testing protocols

OR

Provide proof of applicable exemption including any required supporting documentation

Medical, religious, state and remote-only work exemptions are available.

Scheduled Weekly Hours

40