Utilization Management Nurse- WAH Nationwide

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


Scheduled Weekly Hours

40

Company info

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