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DescriptionThe 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.ResponsibilitiesCreating Healthy Communities is good for the Soul. Join Us! 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.Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment

Coordinates and communicates with providers, members, or other parties to facilitate appropriate discharge planning including to assist with social determinants and closing gaps

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

Required QualificationsLicensed Registered Nurse (RN) Compact license required, with no disciplinary action

At least 3 years of varied clinical nursing experience

Utilization management experience which includes following MCG/Milliman or Interqual guidelines

Prior clinical experience preferably in an acute care, hospital, skilled or rehabilitation clinical setting

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Ability to work independently under general instructions and with a team

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred QualificationsBachelor's degree in nursing (BSN)

CCM Certification

Health Plan experience

Previous Medicare/Medicaid Experience

Call center or triage experience

Work-At-Home RequirementsWAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required

Satellite and Wireless Internet service is NOT allowed for this role

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional InformationHours for this role are: Monday-Friday 8am-5pm CST, overtime or weekend work may be required based on a business need

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.Scheduled Weekly Hours40Humana 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=HumanaWebsite.

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