Description
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.
Responsibilities
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.
Required Qualifications
• Licensed Registered Nurse (RN) in Florida with no disciplinary action.
• This role is considered patient facing and is part of Humana/Senior Bridge's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• 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 have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required
Preferred Qualifications
• 3+ years' experience in a high volume community or mail order pharmacy practice environment.
• Education: BSN or Bachelor's degree in a related field
• Health Plan experience
• Previous Medicare/Medicaid Experience a plus
• Call center or triage experience
• Bilingual is a plus
Additional Information
Onsite SNF in Tampa and 1 facility in Pinellas County
This position is current work at home but travel will be required to go onsite at various facilities when covid travel restrictions are lifted.
Scheduled Weekly Hours
40
Job Type: Full time