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Humana Healthy Horizons in Kentucky is seeking a Utilization Management Nurse 2 who will utilize 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 Utilization Management Nurse 2 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.

Use your skills to make an impact
 

Required Qualifications

• Must live within 30 miles of Lexington or Louisville, Kentucky.
• Licensed Registered Nurse (RN) in the state of Kentucky with no disciplinary action and ability to hold licenses in multiple states without restriction.
• Minimum one (1) year utilization management experience.
• Minimum two (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.
• This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance. in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

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 - English and Spanish.

Additional Information

• Workstyle: This position’s workstyle includes both remote and field work. Field visits include onsite visits to facilities in Louisville, KY and neighboring areas as well as facilities in Lexington, KY and surrounding areas.
• Travel: Around 75 - 80%, 4 days weekly.
• Workdays & Hours: Monday-Friday 8:00 AM - 6:00 PM EST with rotating on-call coverage during weekends and holidays.
• Language Assessment: Any Humana employee 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.

Work from Home Internet Statement

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:

• 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.
• Employees 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 Hom