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.
- 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.
- 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.
- Description Of Benefits: Includes medical, dental, and vision benefits, 401(k) retirement savings plan, time off, short-term and long-term disability, life insurance, and many other opportunities.
About Us
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.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.