Experienced Telephonic Utilization Management Nurse – Pacific Southwest Region – Remote Opportunity to Drive Healthcare Excellence

Introduction to Humana and Our Mission At Humana, we are dedicated to putting health first for our teammates, customers, and the company as a whole. Through our comprehensive insurance services and CenterWell healthcare services, we strive to make it easier for millions of people to achieve their best health. Our efforts are focused on delivering high-quality care and service when it's needed most, leading to a better quality of life for individuals with Medicare, Medicaid, families, and communities at large. Job Overview We are seeking an experienced and skilled Telephonic Utilization Management Nurse to join our team in the Pacific Southwest Region. As a Telephonic Utilization Management Nurse, you will utilize your clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. This role requires a strong and diverse skillset, including excellent communication skills, independent critical thinking, and the ability to interpret criteria, policies, and procedures to provide the best level of treatment, care, or services for our members. Key Responsibilities Coordinate and communicate with providers, MDs, and administrative staff to facilitate optimal care and treatment for our members. Review utilization management inpatient admission and clinical information to determine the appropriate level of care in a fast-paced environment. Understand resources and role responsibilities, as well as reporting structures, to ensure seamless collaboration and effective decision-making. Make decisions regarding your own work methods, occasionally in ambiguous situations, and receive guidance where needed to ensure compliance with CMS and NCQA requirements. Promote collaboration within your team and with other departments to drive success and improve consumer experiences. Qualifications and Requirements To be successful in this role, you will need to possess the following essential qualifications: Licensed Registered Nurse (RN) in the states of AZ, CO, NM, or a compact license, with no disciplinary action. Ability to work business hours in the MST/PST time zone. 2+ years of prior clinical experience in either an acute care or post-acute setting. Good typing skills and proficiency using MS Office Word, Excel, and Outlook. Ability to work independently under general instructions and as part of a team. Passion for contributing to an organization focused on continuously improving consumer experiences. Willingness to obtain additional non-compact state licensure. Preferred Qualifications While not required, the following qualifications are preferred: Education: BSN. Prior utilization management experience. Health plan experience. Previous Medicare/Medicaid experience. Experience working with CMS and/or MCG guidelines. Call center or triage experience. CA, NV, or HI licensure a plus. Skills and Competencies To excel in this role, you will need to possess the following skills and competencies: Strong clinical knowledge and critical thinking skills. Excellent communication and interpersonal skills. Ability to work independently and as part of a team. Strong problem-solving and decision-making skills. Ability to interpret criteria, policies, and procedures. Proficiency in MS Office and electronic medical records. Career Growth Opportunities and Learning Benefits At Humana, we are committed to the growth and development of our associates. As a Telephonic Utilization Management Nurse, you will have access to a range of career growth opportunities, including: Professional development and training programs. Mentorship and coaching from experienced professionals. Opportunities for advancement and career progression. Access to a range of educational resources and tools. Work Environment and Company Culture At Humana, we pride ourselves on our positive and supportive work environment. As a Telephonic Utilization Management Nurse, you will be part of a collaborative and dynamic team that is dedicated to delivering exceptional care and service to our members. Our company culture is built on the following values: Integrity and ethics. Respect and empathy. Excellence and innovation. Teamwork and collaboration. Compensation, Perks, and Benefits We offer a competitive salary range of $69,800 - $96,200 per year, depending on experience and qualifications. In addition to your salary, you will also be eligible for a range of perks and benefits, including: Medical, dental, and vision benefits. 401(k) retirement savings plan. Time off, including paid time off, company and personal holidays, volunteer time off, and paid parental and caregiver leave. Short-term and long-term disability. Life insurance. Conclusion If you are a motivated and experienced Telephonic Utilization Management Nurse looking for a new challenge, we encourage you to apply for this exciting opportunity. As a member of our team, you will have the chance to make a real difference in the lives of our members and contribute to the success of our organization. Don't miss out on this opportunity to join our caring community and help us put health first. Apply today and let's build the future together! Apply for this job