Remote Telephonic Utilization Management Nurse (Pacific Southwest Region)

The Telephonic Utilization Management Nurse utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

Helping our Medicare population be healthy and stay healthy! The Utilization Management Nurse 2 utilizes their clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate level of treatment, care or services for members.

• Coordinates and communicates with providers, MDs, and administrative staff to facilitate optimal care and treatment
• Review UM inpatient admission and clinical information to determine appropriate level of care in a fast-paced environment
• Understands resources and role responsibilities as well as reporting structure
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
• Follows established guidelines/procedures to ensure all work is compliant with CMS and NCQA requirements
• Promotes collaboration within own team as well as others

Required Qualifications

• Licensed Registered Nurse (RN) in the states of AZ, CO, NM or a compact license covering all 3 states, with no disciplinary action
• Will need to have a CA, NV and HI licensure or have the ability to attain all 3 additional licensures through endorsement
• Must be able to work business hours in MST/PST time zone
• 3+ years of prior clinical experience in an acute care and/or post-acute setting
• Must have good typing skills and proficiency using MS Office Word, Excel and Outlook
• 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

Preferred Qualifications

• 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

Work-At-Home Requirements

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

Additional Information

• Hours for this role are: Monday-Friday, 8am-5pm MST or PST with a weekend rotation. Some flexible scheduling offered

#LI-Remote

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting in Las Vegas, Nevada. The pay range may be higher or lower based on geographic location and individual pay decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$69,800 – $96,200 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.