Telephonic Utilization Management Nurse - Acute Care (Gulf South Region) - Madison Wisconsin

Company: Humana
Location: Madison, Wisconsin
Posted On: 05/18/2024

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. 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 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.

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  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.
  
  
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  Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
  
  
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  Follows established guidelines/procedures
  
  
  Daily Activities:
  
  
  
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    Reconciling census and updating existing cases as needed.
    
    
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    Reviewing clinical information on all new admissions and making utilization determinations in accordance with Humana senior products UM policies. Facilitating the transition of care.
    
    
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    Reviewing clinical information for the appropriateness as compared to MCG; Communicating case status to the facility as needed.
    
    
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    Facilitating discharge planning and transition of care processes through outreach to the member and collaboration with the member's health care team to maximize the member's benefits and resources. This includes case management referrals and any other specific market initiatives.
    
    
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    Performing concurrent review and/or discharge planning for all Humana Medicare/Medicaid hospitalized members
    
    
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    Updating UM cases as needed (e.g., diagnosis, notes, discharge tools, discharge dates and dispositions) and in accordance with Humana senior products policies and procedures.
    
    
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    Assisting/educating facility staff regarding Humana's processes for prior authorization, etc.
    
    
    Use your skills to make an impact
    Required Qualifications
    
    
    
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      Licensed Registered Nurse (RN) compact licensure with no disciplinary action
      
      
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      3+ years of prior acute care clinical experience
      
      
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      Comprehensive knowledge of Microsoft Word, Outlook and Excel
      
      
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      Ability to work independently under general instructions and with a team
      
      
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      Must be passionate about contributing to an organization focused on continuously improving consumer ---
      
      
      Preferred Qualifications
      
      
      
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        Bachelor's degree in nursing (BSN)
        
        
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        Experience in utilization management is strongly preferred
        
        
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        Health Plan experience
        
        
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        Previous Medicare experience a plus
        
        
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        Milliman MCG experience preferred
        
        
        Work-At-Home Requirements
        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:
        
        
        
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          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
          
          
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          Satellite, cellular and microwave connection can be used only if approved by leadership
          
          
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          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
          
          
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          Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job
          
          
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          Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
          
          
          Additional Information
          
          
          
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            Hour are Monday-Friday 8:00am-5:00pm EST/CST
            
            
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            This is a remote position
            
            
            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.$69,800 - $96,200 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
            Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.
            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 because he or she is a protected veteran. It is also the policy of ---Humana---to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
            Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website. More...

                

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