The Utilization Management Nurse 2 uses clinical nursing skills to support the coordination, documentation and communication of medical services and benefit administration determinations for Humana's Kentucky Medicaid Plan. You will perform medical necessity reviews, including initial and concurrent authorization decisions, using established clinical criteria and independent clinical judgment. The Utilization Management Nurse 2 also meaningfully contributes in facilitating comprehensive, proactive, and barrier-focused discharge planning to home or a lower level of care.
The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills. These skills are used towards interpreting criteria, policies, and procedures. The goal is to provide the best and most appropriate treatment, care, or services for members.
- Coordinate and communicate with providers, members, or other parties to facilitate care and treatment.
- Collaborate with members, their families, and care providers to develop individualized discharge plans that address clinical needs and promote continuity of care, whether virtually or in-person.
- Maintain compliance with state regulations and organizational standards for coordinated member discharge, ensuring that you document all plans.
- Perform initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions.
- Engage providers by telephonic, virtual, and onsite collaboration.
- Lead in-depth discharge planning and ensure post-discharge resources are in place
- Follow established guidelines/procedures.
Use your skills to make an impact Required Qualifications- Licensed Registered Nurse (RN) in the state of Kentucky, in good standing with no disciplinary action.
- 2+ years of progressive clinical experience in an acute care, skilled nursing, or rehabilitation setting (preferred).
- 1+ year of utilization management experience.
- Maintain compliance with state regulations and organizational standards, ensuring that we coordinate and document member discharge plans and communicate them.
- Experience performing initial and concurrent reviews for medical service requests, with the ability to interpret clinical criteria and apply judgment to support appropriate use and benefit administration.
- Experience engaging with providers and care teams through telephonic, virtual, or onsite interactions to facilitate authorizations and support member-centered discharge planning.
- Strong proficiency in Microsoft Office Suite, including Word, Excel, and PowerPoint.
Preferred Qualifications- Bachelor's degree in nursing.
- MCG experience.
- Experience in discharge planning, transitions of care, and familiarity with community-based resources and social determinants of health.
- Health plan experience.
- Medicaid experience.
- Bilingual in English and another language. A Language Proficiency Assessment will be conducted to evaluate fluency in reading, writing, and speaking in both languages prior to assignment to a dedicated member service line.
Additional Information- Schedule/Time Zone: 8-hour shift, Monday-Friday, between 8:00 AM and 6:00 PM EST, with rotating on-call coverage and oversight during weekends and holidays (rotation every 13-14 weeks).
- Work Location: Kentucky or within bordering counties within a 20-mile radius of Kentucky (OH, IN).
- Work Style: Remote, based in Kentucky or within a 20-mile radius of bordering Kentucky counties (OH, IN).
- Travel Requirements: Up to 10% travel. This role may include visits to onsite facilities, depending on the supported region, in addition to telephonic support. Occasional local travel is required for onsite discharge planning and provider collaboration. Ability to attend 1-2 annual in-person meetings at the Louisville Waterside office.
Work-at-Home (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.
TB Statement: This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
Driving Statement: This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.
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.
Language Assessment Statement: Any Humana employee who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.
Work at Home RequirementsTo 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. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours40
Pay RangeThe 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 BenefitsHumana, 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
