Location: Birmingham, AL
Location Type: Birmingham – Remote
Additional Location: FL; GA; ID; IN; KY; LA; MN; MS; OH; TN;
The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting 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, and requires minimal direction and receives guidance where needed.
- Follows established guidelines/procedures
- Reconciling census and updating existing cases as needed.
- Reviewing clinical information on all new admissions and making utilization determinations in accordance with Humana senior products UM policies. Facilitating the transition to alternate level of care.
- Reviewing clinical information for the appropriateness of the level of care (e.g., observation versus inpatient status). Communicating case status to the facility as needed.
- Facilitating discharge planning and transition of care processes through outreach to the member and collaboration with the member’s health care team to maximize the member’s benefits and resources. This includes case management referrals and any other specific market initiatives.
- Performing concurrent review and/or discharge planning for all Humana Medicare/Medicaid hospitalized members
- Updating UM cases as needed (e.g., diagnosis, notes, discharge tools, discharge dates and dispositions) and in accordance with Humana senior products policies and procedures.
- Assisting/educating facility staff regarding Humana’s processes for prior authorization, observation status, etc.
- Licensed Registered Nurse (RN) in the appropriate state with no disciplinary action
- Must also have the ability to obtain an RN Compact Nurse Licensure
- 3-5 years of prior acute care clinical experience
- Comprehensive knowledge of Microsoft Word, Outlook and Excel
- 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
- Bachelor’s degree in nursing (BSN)
- Experience in utilization management is strongly preferred
- Health Plan experience
- Previous Medicare experience a plus
- Milliman MCG experience preferred
To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
- At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
- Satellite, cellular and microwave connection can be used only if approved by leadership
- Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense
- Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
- Must be available to work: Monday-Friday 8am-5pm CST or EST
- This is a remote position
Scheduled Weekly Hours
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