Utilization Management Registered Nurse
About the role
The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services including Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME).
Responsibilities
- Use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
- Make determinations based on information provided by the attending physician and other care providers.
- Complete request determinations within established processing time frames.
- Communicate with providers, members, or other parties to facilitate care and treatment.
- Help deliver coordinated care for our members.
- Understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
Requirements
- Must hold Compact Registered Nurse (RN) license in your state of residence.
- Must have greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
- Must be passionate about contributing to an organization focused on improving consumer experiences.
Preferred Qualifications
- Previous experience in utilization management/utilization review for a health plan or acute care setting.
- Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
- Experience working in a fully remote, metrics-focused role.
- Experience as an MDS Coordinator or discharge planner in an acute care setting.
- Experience as an RN for a Medicare Certified Home Health agency.
- Health Plan or Medicare / Medicaid Experience.
Additional Information
- Work-at-Home Information: Self-provided internet service must meet minimum download and upload speeds. Employees in certain states may be reimbursed for internet expenses.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
- Travel: Occasional travel to Humana's offices for training or meetings may be required.
- Scheduled Weekly Hours: 40 hours per week.
- Pay Range: $71,100 - $97,800 per year.
- This job is eligible for a bonus incentive plan.
Description Of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits include medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance, and many other opportunities.
About Us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell 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 and Medicaid, families, individuals, military service personnel, and communities at large.