Experienced Utilization Management Nurse – Part-Time Remote Opportunity in Gulf South Region for Humana, Focusing on Clinical Excellence and Member Care Coordination

Introduction to Humana and Our Mission

At Humana, we are driven by a profound passion for putting health first – for our teammates, our customers, and our company. Through our comprehensive insurance services and CenterWell healthcare services, we strive to make it easier for millions of people to achieve their best health. Our efforts are centered around delivering the care and service our members need, when they need it, leading to a better quality of life for individuals with Medicare, Medicaid, families, and communities at large.

About the Role: Utilization Management Nurse

We are seeking a skilled and compassionate Utilization Management Nurse to join our team on a part-time basis. This remote role offers the freedom and flexibility to work from the comfort of your own home, with a schedule that includes 20 hours per week, between 8am-5pm EST/CST, Monday through Friday. The ideal candidate will have a strong clinical background, excellent communication skills, and the ability to work independently with minimal direction.

Key Responsibilities

• Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.
• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment, ensuring that members receive the best and most appropriate treatment, care, or services.
• Make decisions regarding own work methods, occasionally in ambiguous situations, and require minimal direction, receiving guidance where needed.
• Follow established guidelines and procedures, with the ability to interpret and apply them in a practical context.
• Reconcile census and update existing cases as needed, reviewing clinical information on all new admissions and making utilization determinations in accordance with Humana's senior products UM policies.
• Facilitate discharge planning and transition of care processes through outreach to the member and collaboration with the member's healthcare team to maximize the member's benefits and resources.
• Perform concurrent review and/or discharge planning for all Humana Medicare/Medicaid hospitalized members, updating UM cases as needed and in accordance with Humana's senior products policies and procedures.
• Assist and educate facility staff regarding Humana's processes for prior authorization, observation status, etc.

Essential Qualifications

• Licensed Registered Nurse (RN) with compact licensure and no disciplinary action.
• 3+ years of prior acute care clinical experience, with a comprehensive understanding of clinical practices and procedures.
• Excellent communication skills, both verbal and written, with the ability to effectively communicate with members, providers, and other stakeholders.
• Ability to work independently under general instructions and as part of a team, with a strong sense of self-motivation and discipline.
• Comprehensive knowledge of Microsoft Word, Outlook, and Excel, with the ability to learn and adapt to new software and systems.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences, with a commitment to delivering high-quality care and service.

Preferred Qualifications

• Bachelor's Degree (BSN), with a strong foundation in nursing principles and practices.
• Utilization management experience, with a deep understanding of UM policies and procedures.
• Health Plan experience, with knowledge of healthcare systems and operations.
• Previous Medicare experience, with a comprehensive understanding of Medicare policies and procedures.
• Milliman MCG experience, with knowledge of clinical guidelines and criteria.

Career Growth Opportunities and Learning Benefits

At Humana, we are committed to the growth and development of our teammates. As a Utilization Management Nurse, you will have access to a range of training and development opportunities, including clinical education, leadership development, and career advancement programs. Our goal is to support your professional growth and help you achieve your career aspirations, while delivering high-quality care and service to our members.

Work Environment and Company Culture

Humana is a dynamic and inclusive organization, with a strong commitment to diversity, equity, and inclusion. Our company culture is built on a foundation of respect, empathy, and compassion, with a focus on delivering exceptional care and service to our members. As a remote worker, you will be part of a virtual team, with opportunities to collaborate and connect with colleagues across the country.

Compensation, Perks, and Benefits

We offer a competitive compensation package, with a pay range of $69,800 - $96,200 per year, depending on experience and location. Our benefits package includes medical, dental, and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance, and many other opportunities. We also offer a bonus incentive plan, based on company and individual performance.

Conclusion

If you are a motivated and compassionate Utilization Management Nurse, with a passion for delivering high-quality care and service, we encourage you to apply for this exciting opportunity. As a part-time remote worker, you will have the flexibility to work from home, with a schedule that fits your needs. Join our team and be part of a dynamic and inclusive organization, committed to putting health first and delivering exceptional care and service to our members.

Apply now and take the first step towards a rewarding and challenging career as a Utilization Management Nurse at Humana. We look forward to receiving your application and exploring how you can contribute to our mission of delivering high-quality care and service to our members.