Utilization Management Registered Nurse

Become a part of our caring community

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.

As a Utilization Management Registered Nurse

• You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
• Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
• You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?)
• You will communicate with providers, members, or other parties to facilitate care and treatment.
• You will help deliver coordinated care for our members
• You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.

Required Qualifications

• 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
• Call center or triage experience
• BSN or bachelor's degree in a related field

Additional Information

• 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.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Work at Home Requirements: 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. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Florida Background Screening Requirements: Notice for candidates applying to this position from a Florida work location, including Florida home-based work location. This position is subject to Florida Level 2 background screening through the Care Provider Background Screening Clearinghouse. For information about the screening process and requirements, visit: https://info.flclearinghouse.com.

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$71,100 - $97,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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