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The Utilization Management Nurse 2 uses 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.This role 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.
Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment.
You will report to the Manager Care Management and support the Medicaid CM Team.
In this role you will:
- Understand department, segment, and organizational strategy and operating goals, 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 the state of Louisiana with no disciplinary action with the ability to be licensed in multiple states
- 3+ years of varied RN nursing experience (Strong med surg, ICU, ER, acute experience)
- Experience in Utilization Management Review and/or Prior Authorization
- Comprehensive knowledge of Microsoft Word, Outlook and Excel
- Ability to work independently under general instructions and with a team
- Location: Must reside and conduct work in the state of Louisiana
- Hours: Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM Central Time, over-time and a weekend rotation may be requested to meet business needs
Preferred Qualifications
- Education: BSN or Bachelor's degree in a related field
- Health Plan experience
- Previous Medicare/Medicaid Experience a plus
- Bilingual Creole OR Spanish is a plus
- Experience with MCG guidelines
Additional Information
Workstyle: Remote work at home
Location: Must reside in and perform work in the state of Louisiana
Schedule: Monday through Friday 8:00 AM to 5:00 PM in most time zones, with ability to work over-time, weekends as needed to support business needs.
Training: The training program will span approximately four weeks, with sessions scheduled from 8:00 AM to 5:00 PM. Additional virtual training opportunities will also be provided.
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 required.
- 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.
Interview Format
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.
Section 1121 of the Louisiana Code of Governmental Ethics states that current or former agency heads or elected officials, board or commission members or public employees of the Louisiana Health Department (LDH) who work directly with LDH's Medicaid Division cannot be considered for this opportunity. A separation of two (2) or more years from LDH is required for consideration. For more information please visit: Louisiana Board of Ethics (la.gov)
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours
40Pay 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 yearThis 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 that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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