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Utilization Management Review Nurse 2 ID-13066

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

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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



Use your skills to make an impact

Required Qualifications

  • Licensed Registered Nurse (RN) with no disciplinary action in the state of Ohio.
  • 3 - 5 years of Medical Surgery, Heart, Lung or Critical Care Nursing experience required
  • Previous experience in utilization management required
  • Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
  • Comprehensive knowledge of Microsoft Word, Outlook and Excel
  • Ability to work independently under general instructions and with a team
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences.
  • Must be able to work during the following hours: Monday- Friday from 9am-5:30pm EST.



Preferred Qualifications

  • Bachelor's degree
  • Health Plan experience
  • Previous Medicare/Medicaid Experience a plus
  • Call center or triage experience
  • Bilingual is a plus



Additional Information

About Humana

Your growth is what drives Humana forward.

  • When you get here, the journey is just beginning.
  • Our leaders are committed to understanding what you need to grow
  • Because we don't grow without you
  • This is a place where our nurses influence the C-suite
  • Where software engineers change lives
  • Where every associate can build a professional path where they learn and thrive
  • Through our commitments to wellbeing and work-life balance, we support each associate's personal health, purpose, work style, sense of belonging, and security
  • Because finding new ways to put health first-for our members and patients and our associates alike-is what we do



Work at Home Guidance

To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
  • Satellite, cellular and microwave connection can be used only if approved by leadership
  • Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
  • Humana will provide Home or Hybrid Home/Office associates 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
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