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. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
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.
- 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: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
- Scheduled Weekly Hours: 40
- Pay Range: $71,100 - $97,800 per year
Description Of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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.