Utilization Management Nurse

Become a part of our caring community

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.
This role 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.

You will report to the Manager Care Management and support the Medicaid CM Team.
In this role you will:

- Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

- Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

- Follows established guidelines/procedures.

Use your skills to make an impact

Required Qualifications

- Licensed Registered Nurse (RN) in the state of Louisiana with no disciplinary action with the ability to be licensed in multiple states

- 3+ years of varied RN nursing experience

- Comprehensive knowledge of Microsoft Word, Outlook and Excel

- Ability to work independently under general instructions and with a team

- Location: Must reside and conduct work in the state of Louisiana

- Hours: Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM Central Time, over-time and a weekend rotation may be requested to meet business needs

Preferred Qualifications

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

- Experience in Utilization Management Review and/or Prior Authorization

- Health Plan experience

- Previous Medicare/Medicaid experience a plus

- Experience with MCG guidelines

- Compact Nursing License

Additional Information

Workstyle: Remote work at home

Location: Must reside in and perform work in the state of Louisiana

Schedule: Monday through Friday 8:00 AM to 5:00 PM in most time zones, with ability to work over-time, weekends as needed to support business needs.

Training: The training program will span approximately four to six weeks, with sessions scheduled from 8:00 AM to 5:00 PM. Additional virtual training opportunities will also be provided.
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 required.

- Satellite, cellular and microwave connection can be used only if approved by leadership.

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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.

Section 1121 of the Louisiana Code of Governmental Ethics states that current or former agency heads or elected officials, board or commission members or public employees of the Louisiana Health Department (LDH) who work directly with LDH's Medicaid Division cannot be considered for this opportunity. A separation of two (2) or more years from LDH is required for consideration. For more information please visit: Louisiana Board of Ethics (la.gov)
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