Utilization Management Nurse, Part-Time (Gulf South Region)

Become a part of our caring community and help us put health first
 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.

The 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.

• 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, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Follows established guidelines/procedures

 

Daily Activities:

• Reconciling census and updating existing cases as needed.
• Reviewing clinical information on all new admissions and making utilization determinations in accordance with Humana senior products UM policies. Facilitating the transition to alternate level of care.
• Reviewing clinical information for the appropriateness of the level of care (e.g., observation versus inpatient status). Communicating case status to the facility as needed.
• Facilitating discharge planning and transition of care processes through outreach to the member and collaboration with the member’s health care team to maximize the member’s benefits and resources. This includes case management referrals and any other specific market initiatives.
• Performing concurrent review and/or discharge planning for all Humana Medicare/Medicaid hospitalized members
• Updating UM cases as needed (e.g., diagnosis, notes, discharge tools, discharge dates and dispositions) and in accordance with Humana senior products policies and procedures.
• Assisting/educating facility staff regarding Humana’s processes for prior authorization, observation status, etc.

​ **This is a 20 hour per week part-time position with working hours between 8am-5pm EST/CST Monday-Friday. (8 of the 20 hours worked will be required to work on either Monday or Friday; the remaining 8 and 4 hour schedule is flexible to work within the week) **

Use your skills to make an impact
 

Required Qualifications

• Licensed Registered Nurse (RN) compact licensure with no disciplinary action
• 3+ years of prior acute care clinical experience
• Comprehensive knowledge of Microsoft Word, Outlook and Excel
• Excellent communication skills both verbal and written
• Ability to work independently under general instructions and with a team
• Must be passionate about contributing …