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 for Humana’s Kentucky Medicaid Plan. 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 will work both telephonically and onsite, interacting with providers and members, to determine appropriateness of services. The UM RN will use 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 Medicaid members.

Responsibilities for this position include:

• 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.

There are two positions available:

1) The workstyle will be a combination work at home and also will include onsite visits to onsite facilities within in the Louisville and surrounding area. The onsite travel may be required up to 4 days a week. Must reside within 30 miles of Louisville.

2) The workstyle will be a combination work at home and also will include onsite visits to onsite facilities in the Lexington and surrounding area. The onsite travel may be required up to 4 days a week. Must reside within 30 miles of Lexington.

This department provides coverage Monday-Friday 8:00 AM -6:00 PM Eastern Time with rotating on-call coverage and oversight during weekends and holidays.

Use your skills to make an impact
 

Required Qualifications

• Licensed Registered Nurse (RN) in the state of Kentucky with no disciplinary action and ability to hold licenses in multiple states without restriction.

• Minimum 1 year in-hospital Utilization Management experience

• Minimum 2 years Progressive clinical experience in an acute hospital setting, skilled nursing or rehabilitation clinical setting

• Strong Proficiency with MS Office Suite to include Word, Excel, Power Point, to include quickly learn and navigate new systems and application as well as troubleshoot and resolve platform and connectivity issues

• Ability to work independently under general instructions and with a team

Preferred Qualifications

• Bachelor's Degree

• MCG experience

• 1+ year Care Management experience in an acute care, skilled or Rehabilitation clinical setting 

• Certified Case Manager, CCM

• Health Plan experience

• Medicaid experience

• Bilingual in English and Spanish - Language Proficiency Assessment will be performed to test fluency in reading, writing and speaking in both languages before placing on a dedicate line to service our members.

Additional Information

Workstyle: Combination remote work at home and field based

There are two positions available:

• 1) The workstyle will be a combination work at home and also will include onsite visits to onsite facilities within in the Louisville and surrounding area.

• 2) The workstyle will be a combination work at home and also will include onsite visits to onsite facilities in the Lexington and surrounding area.

Location: Must reside within 30 miles of Lexington or Louisville Kentucky.

Schedule: Monday-Friday 8:00 AM -6:00 PM Eastern with rotating on-call coverage during weekends and holidays.

Travel: About 75-80%, 4 days weekly

Work-At-Home Requirements To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• Satellite, cellular and microwave connection can be used only if approved by leadership.

• Employees who live and work from Home in the state of California, Illin