Utilization Management Pre-Auth RN

Profile

Description

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.

Responsibilities

Core hours for this role are 7:00 a.m. to 5 p.m. CST - specific hours and scheduling will be determined during training and by leader.

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. Utilization Management Nurse 2 will collaborate with other health care providers in reviewing actual and proposed medical care and services against established CMS and Humana Medical coverage guidelines. This is a utilization management position. In this role you will:

Complete clinical review of cases by reviewing medical records and applying appropriate criteria.

Utilize Clinical knowledge to determine if medical appropriateness has been met, and if not, collaborate with Regional Medical Directors to complete review.

Manage case reviews keeping compliance, quality and productivity in mind.

Participate in special projects/ stretch assignments as assigned by the Clinical Review Team, Front Line Leader

Core hours for this role are 7:00 a.m. to 5 p.m. CST - specific hours and scheduling will be determined during training and by leader.

Role Essentials

Active RN License in the state that you reside

3 years of prior clinical experience as a RN

The ability to work from home in a dedicated office

Efficient in use of Microsoft products (i.e. Word, Excel, etc.)

Ability to work independently, under general instructions, and with a team.

Computer proficiency: comfortable working with and on computers as well as within multiple systems simultaneously

Strong verbal and written communication skills

Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role).

Role Desirables

Utilization management experience

Pre-Authorization experience

Call Center or Triage experience

Health Plan/Insurance experience

Medicare/Medicaid experience

Durable Medical Equipment (DME) experience

Education: BSN or Bachelor's degree in a related field

Experience working in a virtual environment

Bilingual in Spanish/English is a plus

Additional Information

Working in the state of Arizona must comply with the Tobacco Free Hiring Policy and upon offer will be subjected to nicotine testing as part of a 10-panel drug test

Interview Format:

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first round interview, you will receive an email correspondence inviting you to participate in a Modern Hire interview. In this interview, you will have a set of interview questions and you will provide recorded video responses to each question. You should anticipate this interview to take about 15 - 20 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Alert : Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana's secure website.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com