Utilization Management Registered Nurse

Humana; South Carolina; Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Remote-friendly/Hybrid/Home-Office

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and support coordination, documentation, and communication of medical services and benefit determinations. You will work with the One Home/Home Solutions Utilization Management team handling post-acute care services (SNF, Home Health, DME) to ensure appropriate care in the right setting.

Reporting to the Manager of Utilization Management, you will perform determinations using established criteria, communicate with providers

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.
• Previous experience in utilization management/utilization review for a health plan or acute care setting (preferred).
• Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual (preferred).
• Experience working in a fully remote, metrics-focused role (preferred).
• Experience as an MDS Coordinator or discharge planner in an acute care setting (preferred).
• Experience as an RN for a Medicare Certified Home Health agency (preferred).
• Health Plan or Medicare / Medicaid Experience (preferred).
• Call center or triage experience (preferred).
• BSN or bachelor's degree in a related field (preferred).

Responsibilities

• 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.
• 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.

Skills

RN license in state

Clinical RN experience

Patient focus

Education

BSN or related bachelor's degree

Job description

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.

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

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

Additional Information

Work-at-Home 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.

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 year

This 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.

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. Learn more about what we offer atHumana.comand atCenterWell.com.

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.