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 Telephonic Utilization Management Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Telephonic Utilization Management Nurse 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.
The ideal candidate for this position will live in the Mountain Time zone; have a background working in home health; an active and unrestricted RN license; prior utilization management experience following MCG/Milliman or Interqual guidelines; prior work at home experience preferred; and strong computer skills using MS Office products and also electronic medical records.
Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action.
Previous experience with home healthcare, IRF or LTACH
At least 3 years of varied clinical nursing experience
Proficient with Microsoft Office products including Word, Excel and Outlook
Ability to work independently under general instructions and with a team
Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required
Ability to provide a designated workspace; free from distractions with the ability to secure any protected information.
Associates working in the state of Arizona must comply with the Tobacco Free Hiring Policy (see details below under Additional Information) and upon offer will be subjected to nicotine testing as part of a 10 panel drug test
Previous experience in utilization management
Familiarity with CMS criteria
Telephonic care coordination experience
Prior use of MCG/Milliman or Interqual guidelines
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Prior case management experience
Bilingual is a plus
The following policy applies ONLY to associates working in the state of Arizona: Humana is committed to providing a safe and healthy work environment and to promoting the health and well-being of its associates. Effective April 1, 2011, Humana has adopted a tobacco-free hiring policy that will promote a healthier workplace and will not hire users of tobacco and nicotine products. If you have any questions, please consult with your recruiter.
Scheduled Weekly Hours