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. Responsibilities Use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. 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 members. 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 an 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. 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. Travel While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. 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, volunteer time off, paid parental and caregiver leave), short‑term and long‑term disability, life insurance and many other opportunities. 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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our accessibility resources. #J-18808-Ljbffr