Utilization Management Nurse (Central Region)
About the position
The Utilization Management Nurse 2 at Humana plays a crucial role in ensuring that members receive the appropriate medical services and benefits they need. This position requires a blend of clinical nursing skills, effective communication, and independent critical thinking to interpret criteria, policies, and procedures. The nurse will coordinate and communicate with healthcare providers, members, and other stakeholders to facilitate discharge planning and address social determinants of health, thereby closing gaps in care. In this role, the nurse will review inpatient admissions and clinical information to determine the appropriate level of care required for each member. The Utilization Management Nurse 2 must understand the department's and organization's strategies and objectives, ensuring that their work aligns with these goals. The position often involves making decisions in ambiguous situations, requiring minimal direction while still being open to guidance when necessary. Adherence to established guidelines and procedures is essential to maintain the quality and integrity of care provided to members.
Responsibilities
Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations.
,
Coordinate and communicate with providers, members, or other parties to facilitate appropriate discharge planning.
,
Review UM inpatient admission and clinical information to determine the appropriate level of care.
,
Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
,
Make decisions regarding work methods, occasionally in ambiguous situations, with minimal direction and guidance as needed.
,
Follow established guidelines and procedures.
Requirements
Licensed Registered Nurse (RN) in the appropriate state with no disciplinary action.
,
3+ years of prior clinical experience, preferably in an acute care hospital clinical setting.
,
Utilization Management experience is required.
,
Milliman/MCG experience is required.
,
Comprehensive knowledge of Microsoft Word, Outlook, and Excel.
,
Excellent communication skills, both verbal and written.
,
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.
Nice-to-haves
Bachelor's degree in nursing (BSN).
,
Health Plan experience.
,
Previous Medicare experience is a plus.
,
CGX experience.
Benefits
Medical, dental, and vision benefits.
,
401(k) retirement savings plan.
,
Paid time off, including company and personal holidays, volunteer time off, paid parental and caregiver leave.
,
Short-term and long-term disability insurance.
,
Life insurance.
,
Opportunities for personal wellness and smart healthcare decisions.
Apply Now
The Utilization Management Nurse 2 at Humana plays a crucial role in ensuring that members receive the appropriate medical services and benefits they need. This position requires a blend of clinical nursing skills, effective communication, and independent critical thinking to interpret criteria, policies, and procedures. The nurse will coordinate and communicate with healthcare providers, members, and other stakeholders to facilitate discharge planning and address social determinants of health, thereby closing gaps in care. In this role, the nurse will review inpatient admissions and clinical information to determine the appropriate level of care required for each member. The Utilization Management Nurse 2 must understand the department's and organization's strategies and objectives, ensuring that their work aligns with these goals. The position often involves making decisions in ambiguous situations, requiring minimal direction while still being open to guidance when necessary. Adherence to established guidelines and procedures is essential to maintain the quality and integrity of care provided to members.
Responsibilities
Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations.
,
Coordinate and communicate with providers, members, or other parties to facilitate appropriate discharge planning.
,
Review UM inpatient admission and clinical information to determine the appropriate level of care.
,
Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
,
Make decisions regarding work methods, occasionally in ambiguous situations, with minimal direction and guidance as needed.
,
Follow established guidelines and procedures.
Requirements
Licensed Registered Nurse (RN) in the appropriate state with no disciplinary action.
,
3+ years of prior clinical experience, preferably in an acute care hospital clinical setting.
,
Utilization Management experience is required.
,
Milliman/MCG experience is required.
,
Comprehensive knowledge of Microsoft Word, Outlook, and Excel.
,
Excellent communication skills, both verbal and written.
,
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.
Nice-to-haves
Bachelor's degree in nursing (BSN).
,
Health Plan experience.
,
Previous Medicare experience is a plus.
,
CGX experience.
Benefits
Medical, dental, and vision benefits.
,
401(k) retirement savings plan.
,
Paid time off, including company and personal holidays, volunteer time off, paid parental and caregiver leave.
,
Short-term and long-term disability insurance.
,
Life insurance.
,
Opportunities for personal wellness and smart healthcare decisions.
Apply Now