Utilization Management Nurse

Become a part of our caring community and help us put health first

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.

The UM Nurse 2 will

• Uses clinical knowledge, communication skills, and independent critical thinking skills towards:.

• Interpreting criteria, policies, and procedures related to Long Term Services and Support authorizations to provide the best and most appropriate treatment, care, or services for members.
• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Understand department and organizational strategy and operating objectives, including their linkages to related areas.
• Follow established guidelines/procedures.
• Make decisions regarding own work methods, occasionally in ambiguous situations, requires minimal direction and receives guidance where needed.

• Must reside in Michigan or within 40 miles of the border in Indiana or Ohio.
• Active Registered Nurse (RN) in the state of Michigan with no disciplinary action.
• 1-year previous experience in utilization management/LTSS service authorization.
• At least 2 years prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting, or Medicaid Managed Care Organization.
• 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.

• Bachelor’s or Associate’s Degree in Nursing or other related field.
• Previous Medicare/Medicaid experience.
• NCQA, CM experience.
• Previous experience in discharge planning and/or home health or rehabilitation.
• Bilingual preferred (Spanish, Arabic, Chaldean Neo-Aramaic or other).

• Workstyle:
  This is a remote position.
• Travel:
  May need to attend onsite meetings
• Workdays and
  
  Hours:
  
  Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST).
• Language Assessment Statement:
  Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Humana will provide Home or Hybrid Home/Office employees 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.

As part of our hiring process for this opportunity, we will be using an interviewing technology called Hire Vue to enhance our hiring and decision‑making ability. Hire Vue 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.

Assessment:
If you are selected to move forward, you will receive an email to complete the Virtual Job Experience (VJE). This is an online activity where you will learn more about Customer Care jobs at Humana, try out some of the most common job tasks, and tell us more about yourself. Most people complete the VJE in approximately 30 minutes.

To complete it, you will need a smart phone, computer or tablet with internet access, and speakers/headphones. We do not make job offers to candidates that do not complete the VJE.

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