Utilization Management Registered Nurse

Job Summary 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, including 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 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. Required Qualifications Must hold a Compact Registered Nurse (RN) license in your state of residence. Greater than one year of clinical experience as an RN in a hospital, SNF, Home Health, or acute care setting. Must have a passion for 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. 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 California, Illinois, Montana, or South Dakota will be provided a bi‑weekly payment for their internet expense. Humana will provide telephone equipment appropriate to meet business requirements. 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. Hours 40 hours per week. Pay Range $71,100 - $97,800 per year. This range may vary by geographic location and individual qualifications. The position is eligible for a bonus incentive plan. Benefits Humana offers a comprehensive benefits package, including medical, dental, vision, 401(k) retirement savings, paid time off, volunteer time off, paid parental and caregiver leave, short‑term and long‑term disability, life insurance and more. Equal Opportunity Employer Humana is an equal opportunity employer. It does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. Humana adheres to affirmative action policies and baselines employment decisions on valid job requirements. #J-18808-Ljbffr