The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations for Humana's Kentucky Medicaid Plan. This role has primary responsibility for performing medical necessity reviews, including initial and concurrent authorization decisions, using established clinical criteria and independent clinical judgment. The Utilization Management Nurse 2 also plays a key role 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 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.
- Maintain compliance with state regulations and organizational standards for coordinated member discharge, ensuring all plans are documented and communicated effectively.
- Perform initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions.
- Engage providers via telephonic, virtual, and onsite collaboration as needed.
- Follows established guidelines/procedures.
The schedule for this position will include weekends, typically Wednesday through Sunday from 8:00 AM to 5:00 PM Eastern Time with flexibility to adjust weekdays off with leader approval.
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 InformationWorkstyle: Remote work at home
Location: Must reside in Kentucky or a county that is within contiguous bordering states
Schedule: The schedule for this position will include weekends (Weekend shifts are eligible for a shift differential), from 8:00 AM to 5:00 PM Eastern Time with flexibility to adjust weekdays off with leader approval:
- The position follows a 5-day workweek, which includes both Saturday and Sunday.
- Associates will receive two days off during the week.
- Associates may choose which two weekdays they would like off.
- Once selected, those days off must remain consistent from week to week and cannot vary.
Travel: Travel to the Louisville office about 3-4 times annually.
Work at Home Requirements: 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. 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.
