DescriptionThe 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.
- 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, continued stay reviews, post-discharge calls and discharge planning
- Bachelor's degree
- Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action.
- 3-5 years of Med/Surg, Heart, Lung or Critical Care Nursing experience required
- Previous experience in utilization management required
- Comprehensive knowledge of Microsoft Word, Outlook and Excel
- 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
- Less than 5 years of technical experience
- Case Management Experience
- 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, discharge planning and/or home health or rehab
- Bilingual is a plus
Scheduled Weekly Hours40