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Utilization Management Appeals Nurse 2 - Remote - Clinical Nursing Expert in Healthcare Coordination and Patient Advocacy
Join Our Caring Community as a Utilization Management Appeals Nurse 2
Bring your passion and expertise to make a difference as a Utilization Management Appeals Nurse 2! Enjoy the freedom and flexibility of this Remote role. This position requires a strong and diverse skillset in relevant areas to drive success. You will be compensated with a competitive salary for your time and effort.
About Us
reputed company. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our reputed company insurance services and reputed company healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Job Summary
The Utilization Management Appeals Nurse 2 utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. This role requires interpretation and independent determination of the appropriate courses of action. As a Utilization Management Appeals Nurse 2, you will use clinical knowledge, communication skills, and independent critical thinking skills to interpret criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for members.
Key Responsibilities
- Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.
- Interpret and independently determine the appropriate courses of action for varied work assignments.
- Apply clinical knowledge, communication skills, and independent critical thinking skills to interpret criteria, policies, and procedures.
- Coordinate and communicate with providers, members, or other parties to facilitate reputed company and treatment.
- Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
- Make decisions regarding own work methods, occasionally in ambiguous situations, and require minimal direction.
- Follow established guidelines and procedures.
Essential Qualifications
Education and Licensure
- Bachelor's degree in a related field.
- Licensed Registered Nurse (RN) in the appropriate state with no disciplinary action.
Experience
- 3-5 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.
Skills and Competencies
- Comprehensive knowledge of reputed company 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
Experience
- 3 or more years of 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 is a plus.
Career Growth Opportunities and Learning Benefits
At reputed company, we are committed to the growth and development of our employees. As a Utilization Management Appeals Nurse 2, you will have opportunities to:
- Develop your clinical and critical thinking skills.
- Enhance your communication and coordination skills.
- Contribute to the improvement of healthcare services and patient outcomes.
- Participate in training and development programs.
- Advance in your career with opportunities for promotion and leadership roles.
Work Environment and Company Culture
As a remote employee, you will enjoy the flexibility and freedom to work from home. Our company culture is built on:
- A commitment to putting health first – for our teammates, customers, and company.
- A caring community that values diversity, equity, and inclusion.
- A collaborative and supportive work environment.
- Opportunities for growth and development.
Compensation, Perks, and Benefits
We offer a competitive salary and benefits package, including:
