Experienced Utilization Management Nurse – Remote Opportunity in the Midwest Region for a Dynamic Healthcare Organization

Introduction to Our Organization

At Humana, we are dedicated to putting health first for our teammates, customers, and the company as a whole. Through our comprehensive insurance services and CenterWell healthcare services, we strive to make it easier for millions of people to achieve their best health. Our mission is built on delivering care and service when it's needed most, leading to a better quality of life for individuals with Medicare, Medicaid, families, and communities at large. We believe in fostering a culture of inclusivity, respect, and empowerment, where every associate can thrive and contribute to our shared goal of improving healthcare outcomes.

Role Overview

We are seeking an experienced and compassionate Utilization Management Nurse to join our team in the Midwest Region. As a Utilization Management Nurse, you will play a vital role in coordinating, documenting, and communicating medical services and benefit administration determinations. Your clinical expertise and independent critical thinking skills will be essential in interpreting criteria, policies, and procedures to provide the best possible treatment, care, or services for our members. This is a remote opportunity, offering the flexibility to work from the comfort of your own home while being part of a dynamic and caring community that prioritizes health and well-being.

Key Responsibilities

• Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.
• Coordinate and communicate with providers, members, or other parties to facilitate appropriate discharge planning, including addressing social determinants and closing gaps in care.
• Review utilization management inpatient admission and clinical information to determine the appropriate level of care, ensuring that members receive the most suitable treatment and services.
• Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas, to make informed decisions and contribute to the team's goals.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction, demonstrating autonomy and problem-solving skills.
• Follow established guidelines and procedures, staying up-to-date with the latest policies and best practices in utilization management and nursing care.

Essential Qualifications

To be successful in this role, you will need:

• A current license as a Registered Nurse (RN) in KY, IN, MI, OH, or WV, with no disciplinary action, demonstrating your commitment to professional standards and patient care.
• At least 3 years of prior clinical experience, preferably in an acute care hospital setting, where you have developed strong clinical skills and the ability to work in fast-paced environments.
• Comprehensive knowledge of Microsoft Word, Outlook, and Excel, with the ability to efficiently manage documentation, communication, and data analysis.
• Excellent communication skills, both verbal and written, to effectively interact with members, providers, and other stakeholders, ensuring clear and compassionate communication.
• Ability to work independently under general instructions and as part of a team, demonstrating flexibility, adaptability, and a collaborative mindset.
• A passion for contributing to an organization focused on continuously improving consumer experiences, with a commitment to delivering high-quality care and services.

Preferred Qualifications

While not required, the following qualifications are highly desirable:

• A Bachelor's degree in Nursing (BSN), indicating a strong foundation in nursing principles, practices, and research.
• Health Plan experience, providing an understanding of the complexities of healthcare systems, insurance policies, and benefit administration.
• Previous Medicare experience, offering insight into the specific needs and challenges of this population.
• Utilization Management experience, demonstrating familiarity with the processes and principles of managing healthcare resources and services.
• Milliman/MCG experience, showing expertise in using guidelines and criteria to make informed decisions about patient care and resource allocation.

Work Environment and Culture

At Humana, we pride ourselves on our inclusive and supportive work environment. As a remote associate, you will be part of a distributed team that values collaboration, open communication, and mutual respect. We believe in empowering our associates to take ownership of their work, providing the autonomy to make decisions and the resources to grow professionally. Our culture is built on the principles of integrity, compassion, and excellence, guiding everything we do to improve the health and well-being of our members and communities.

Compensation, Perks, and Benefits

We offer a competitive salary range of $69,800 - $96,200 per year, depending on experience and qualifications. Additionally, this role is eligible for a bonus incentive plan, recognizing individual and company performance. Our comprehensive benefits package includes medical, dental, and vision benefits, a 401(k) retirement savings plan, generous time off policies, short-term and long-term disability, life insurance, and many other opportunities to support your well-being and financial security.

Career Growth Opportunities and Learning Benefits

At Humana, we are committed to the growth and development of our associates. As a Utilization Management Nurse, you will have access to ongoing training, education, and career advancement opportunities, helping you to expand your skills, knowledge, and professional network. Our organization values lifelong learning, providing resources and support for continuing education, certifications, and leadership development. By joining our team, you will become part of a community that prioritizes professional growth, innovation, and excellence in healthcare.

Work-At-Home Requirements

To ensure your success in this remote role, you will need to meet the following technical requirements:

• A reliable internet connection with a minimum download speed of 25 Mbps and an upload speed of 10 Mbps.
• A dedicated workspace that is free from ongoing interruptions, protecting member PHI/HIPAA information.
• Telephone equipment will be provided by Humana to meet the business requirements of your position.

Conclusion

If you are a compassionate and experienced nurse looking for a challenging and rewarding role in utilization management, we encourage you to apply for this exciting opportunity. As a Utilization Management Nurse at Humana, you will be part of a dynamic team that is dedicated to improving healthcare outcomes and making a positive impact on the lives of our members. Join us in our mission to put health first, and take the first step towards a fulfilling and successful career in healthcare. Click "Apply Now" to start your journey with us today!

Apply Now