Utilization Management Review Nurse

Become a part of our caring community

Humana Healthy Horizons in Ohio is seeking a Utilization Management Nurse 2 who 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.

You will be part of a caring community at Humana . When you meet us, you can tell we started as a hometown company. We’re proud of our Louisville roots and, as we’ve grown, that community feeling has spread across all 50 states and Puerto Rico. No matter where you are—whether you’re working from home, from the field, from our offices, or from somewhere in between—you’ll feel welcome here. We’re a caring community made of close-knit teams, cross-country friendships, and inclusive resource groups, all gathered around one big table where everyone’s voice is heard and respected. Community is a verb here. It’s up to each of us to care for it and maintain it. Because the relationships we form will help us deliver better health outcomes for the people we so proudly serve.
The Utilization Management Nurse 2 uses clinical knowledge 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. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods 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 Ohio with no disciplinary action.

- At least 3 years of Medical Surgery, Heart, Lung or Critical Care Nursing experience.

- Previous experience in utilization management.

- Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting

- Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

- Bachelors Degree

- 3 or more years experience in a high volume community or mail order pharmacy practice environment

- Health Plan experience

- Previous Medicare/Medicaid Experience

- Call center or triage experience

- Bilingual

Additional Information

This role is considered patient facing and is part of Humana ’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
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 Hours
40 Pay Range
The 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 - $