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.
Role: Utilization Management Nurse RN
Location: Work at home in CA or NV residence preferred
Humana’s dream is to help our members and our own associates achieve lifelong well-being. Use your clinical experience to work with patients and providers in a nontraditional environment where your knowledge will make a difference. Our associates know their work is vitally important; we strive to ensure we provide perfect service with one-on-one member interactions as a coach, personal nurse, or clinical advisor. Humana’s Perfect Service® means getting the basics done right, delivering value and quality, providing guidance on needs, and being engaged with our members. We want to help our members make the right choices to live life fully. We begin that process by connecting our members with an associate who cares.
Be a part of our Clinical Space – as a Clinical Advisor you will engage our members to develop lifelong wellbeing and health.
Humana is seeking a UM Nurse who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.
The ideal candidate for this position will live in either California or Nevada with a dual RN license preferred; at least 3 years of varied clinical nursing experience; a clinical background in utilization management; experience working with MCG, Milliman or Interqual guidelines; good understanding of CMS/Medicare; and computer proficient with Microsoft Word, Excel and Outlook.
Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using your knowledge of benefit plan design
Recommend services for Humana Plan members utilizing care alternatives available within the community and nationally
Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols
Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions by utilizing established screening criteria
Conduct admission review, post-discharge calls and discharge planning
Active RN license; dual license in CA and NV preferred
Ability to be licensed in multiple states without restrictions
At least 3 years of varied clinical nursing experience
Ability to work independently under general instructions and with a team
Computer proficient in Word, Excel, Outlook and PowerPoint
Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance for Humana systems is 10Mx1M
Ability to provide a designated workspace; free from distractions with the ability to secure any protected information.
Education: BSN or Bachelor’s degree in a related field
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Call center or triage experience
Previous experience in utilization management, case management, discharge planning and/or home health or rehab
Bilingual is a plus
Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.
Interview Format As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn’t missed) inviting you to participate in a Montage Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
Equal Opportunity Employer
It is our policy to recruit, hire, train, and promote people without regard to race, color, religion, sex, national origin, age, sexual orientation, gender identity or expression, disability, or veteran status, except where age, sex, or physical status is a bona fide occupational qualification. View the EEO is the Law poster.
If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this online application process and need an alternative method for applying, you may contact firstname.lastname@example.org for assistance.