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The Utilization Management Nurse uses clinical nursing skills to support the coordination, documentation and communication of medical services and benefit administration determinations. The Utilization Management Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Utilization Management Nurse uses clinical knowledge, towards interpreting criteria and procedures to provide the best treatment, care or services for members. Coordinate and communicate with providers to facilitate optimal care and treatment. Understand 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 receive guidance where needed. Follow established guidelines/procedures.

Use your skills to make an impact
 

Required Qualifications

• Active licensed Registered Nurse (RN) in the state of Virginia or obtain a multi-state license in a state that participates in the enhanced licensure, (eNLC) with no disciplinary action.
• At least 2 years prior utilization management experience preferably in an acute care skilled or rehabilitation clinical or healthplan/hospital setting
• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, 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 oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills,

Preferred Qualifications

• BSN degree
• Experience with MCG/InterQual
• Health Plan experience, Medicare/Medicaid experience

Additional Information

Workstyle: Remote work at Home

Location: Must reside in a state participating in the enhanced nurse compact licensure, (eNLC)

Schedule: Must work a minimum of 8 hours between 8:00AM to 5:00 PM Eastern Time, business needs may require working rotating holidays or weekends.

Travel: Less than 5% to attend onsite market meetings as needed

WAH 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 required; 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 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.

SSN Alert Statement

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana's secure website.

HireVue

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

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

 

$71,100 - $97,800 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits th