Utilization Management Registered Nurse

Humana Inc; New Jersey; Hybrid; USD 71,000 - 98,000; Full time

Job summary

Humana Inc. is seeking a Utilization Management Registered Nurse to interpret and support the coordination, documentation and communication of medical services and benefit determinations while contributing to post-acute care management.

You will work within the One Home/Home Solutions Utilization Management team in a fully remote, metrics-driven environment, handling SNF, Home Health and DME coordination with a focus on patient outcomes and timely determinations.

Qualifications

• Must hold Compact RN license in your state of residence.
• Over 1 year of clinical RN experience in hospital, SNF, Home Health or acute care.
• Preferred knowledge of utilization management criteria such as Milliman Care Guidelines or InterQual.
• Experience in a fully remote, metrics-focused role is preferred.
• BSN or bachelor’s degree in a related field is preferred.

Responsibilities

• You will use clinical nursing skills to interpret and support coordination, documentation and communication of medical services and benefit 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.
• 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.

Skills

RN license

Clinical RN experience

Utilization management knowledge

Medical necessity criteria

MDS Coordinator experience

Discharge planning experience

Medicare/Medicaid experience

Education

BSN or related bachelor’s degree

Job description

## Utilization Management Registered NurseApply: Work at Home - Alabama: Remote Oklahoma: Remote Ohio: Remote New Mexico: Remote New Jersey: Full time: Posted Today: R-431272# **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.# **Use your skills to make an impact**### 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### 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.* 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.**Scheduled Weekly Hours**40**Pay Range**The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$71,100 - $97,800 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.**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.