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

Utilization Management Nurse -Front End Review 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.

Monday through Friday, 8am-5pm EST (must reside in Florida)
Available to work 2 Holiday a year.

The Utilization Management Nurse 2 Front End Review 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.

• Utilize MCG criteria to perform acute concurrent front-end reviews on Humana members to determine medical necessity

• Coordinates and communicates with providers, members, or other parties to facilitate optimal care, treatment and discharge planning, which will include about 50% telephonic outreach

• 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

Use your skills to make an impact
 

Required Qualifications

• Licensed Registered Nurse (RN) in Florida with no disciplinary action

• 3 or more years of clinical experience preferably in an acute care- inpatient hospital setting

• Proficiency using MS Office, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment

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

• Strong general computer skills in an autonomous work setting

Preferred Qualifications

• Bachelor's degree

• Front End Review experience

• Previous experience in Utilization Management 

• CGX experience

• MCG experience

• Health Plan experience

• Previous Medicare/Medicaid Experience 

Additional Information

Workstyle: Remote Work at Home

Location: Must reside in Florida, Supporting Florida Market

Hours: Must be able to work Monday through Friday 8:00 AM 5:00 PM Eastern Time and work 2 holidays annually

Travel: None

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

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

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

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense

• Humana will provide Home or Hybrid Home/Office associates 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

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.  If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided.  Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

SSN Format Humana values personal identity protection. Please be aware that applicants may be asked to prov