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 your skills to make an impact
• 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
• Using established medical criteria, 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

• Required Qualifications
• Use your skills to make an impact
• 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

Qualifications

• Required Qualifications
• Use your skills to make an impact
• 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

Skills

• Use your skills to make an impact
• 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

Benefits

• Medical, dental and vision benefits
• 401(k) retirement savings plan
• Paid time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• Short-term and long-term disability
• Life insurance
• Many other opportunities

Pay

$71,100 - $97,800 per year

Schedule

This is a remote position, with occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40