Remote Utilization Management Nurse (South Central Region) Compact license

Location: San Antonio, TX
Location Type: San Antonio – Remote
Additional Location: AL; FL; GA; ID; IA; LA; ME; MN; MS; MO; MT; NE; NC; OH; OK; OR; PA; SC; TN; UT; WI;
Schedule: Full_time
Req: R-313358

Description

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.

Responsibilities

Creating Healthy Communities is good for the Soul. Join Us! 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
• Coordinates and communicates with providers, members, or other parties to facilitate appropriate discharge planning including to assist with social determinants and closing gaps
• 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

Required Qualifications

• Licensed Registered Nurse (RN) Compact license required, with no disciplinary action
• At least 3 years of varied clinical nursing experience
• Utilization management experience which includes following MCG/Milliman or Interqual guidelines
• Prior clinical experience preferably in an acute care, hospital, skilled or rehabilitation clinical setting
• 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

Preferred Qualifications

• Bachelor’s degree in nursing (BSN)
• CCM Certification
• Health Plan experience
• Previous Medicare/Medicaid Experience
• 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 CST, overtime or weekend work may be required based on a business need
• This is a remote position

#LI-Remote

Scheduled Weekly Hours

40