Utilization Management Registered Nurse
Humana · Utah, United States
- Hybrid
- Full-time
- $84,450 / year
- Utah, United States
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Job highlights
- RN needed for utilization management.
- Manage post-acute care services.
- Ensure members receive appropriate care.
- Use clinical nursing skills daily.
- Requires over one year of RN experience.
About the role
About the Role
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, which 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. 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, make determinations based on information provided by the attending physician and other care providers.
- Complete request determinations within established processing time frames (e.g., 10 reviews per day).
- Communicate with providers, members, or other parties to facilitate care and treatment.
- Help deliver coordinated care for our members.
- 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 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
To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service 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 connections can be used only if approved by leadership.
- Employees who live and work from Home in the states 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.Key skills/competency
- Utilization Management Registered Nurse
- Clinical Nursing Skills
- Medical Services Coordination
- Benefit Administration
- Medical Criteria Interpretation
- Provider Communication
- Member Care Facilitation
- Health Plan Experience
- Medical Necessity Criteria
- Remote Work
Skills & topics
- Utilization Management
- Registered Nurse
- RN
- Case Management
- Healthcare
- Health Plan
- Medical Review
- Post-Acute Care
- SNF
- Home Health
- DME
- Clinical Nursing
- Remote
- Work from Home
How to get hired
- Tailor your resume: Highlight your RN clinical experience, particularly in hospital, SNF, Home Health, or acute care settings. Emphasize any utilization management or review experience.
- Showcase relevant skills: Clearly list your RN license and any experience with medical necessity criteria (Milliman Care Guidelines, Interqual). Mention any call center or triage experience.
- Address remote work requirements: Ensure your resume reflects your ability to work remotely, including a dedicated space and reliable internet (25 Mbps download/10 Mbps upload).
- Prepare for interviews: Be ready to discuss your understanding of utilization management, how you apply clinical judgment, and your passion for improving consumer experiences.
- Understand the role: Research Humana's mission and their focus on improving consumer health outcomes.
Technical preparation
Review clinical nursing standards.,Study medical necessity criteria.,Practice using EHR systems.,Familiarize yourself with insurance processes.
Behavioral questions
Describe a complex case you managed.,How do you handle provider disagreements?,Explain your remote work discipline.,How do you prioritize daily tasks?
Frequently asked questions
- What are the primary responsibilities of a Utilization Management Registered Nurse at Humana?
- As a Utilization Management Registered Nurse at Humana, you will primarily use your clinical nursing skills to interpret, coordinate, document, and communicate medical services. You'll make determinations based on established medical criteria and provider information to ensure members receive the appropriate level of care in the most suitable setting, managing services like SNF, Home Health, and DME.
- What clinical experience is required for the Utilization Management Registered Nurse role at Humana?
- Humana requires candidates for the Utilization Management Registered Nurse position to have greater than one year of clinical experience as a Registered Nurse (RN) in a hospital, Skilled Nursing Facility (SNF), Home Health, or acute care setting. A Compact RN license in your state of residence is also mandatory.
- Is this Utilization Management Registered Nurse position remote?
- Yes, this Utilization Management Registered Nurse position is a work-at-home role. Humana provides specific internet speed requirements and guidance on dedicated workspaces to ensure effective remote work and protection of member information. Occasional travel for training or meetings may be required.
- What preferred qualifications would make my application stronger for the Utilization Management Registered Nurse job at Humana?
- To strengthen your application for the Utilization Management Registered Nurse role at Humana, consider highlighting previous experience in utilization management/review, knowledge of medical necessity criteria (Milliman Care Guidelines, Interqual), experience in a remote, metrics-focused role, or experience as an MDS Coordinator or discharge planner. Health plan, Medicare/Medicaid experience, and call center or triage skills are also beneficial.
- What is the typical workload for a Utilization Management Registered Nurse at Humana?
- While the job description mentions completing request determinations within established processing time frames, it provides an example of '10 reviews per day'. This suggests a metrics-focused role where efficiency and timely case management are key aspects of the workload for a Utilization Management Registered Nurse.
- What kind of benefits does Humana offer to its employees, including the Utilization Management Registered Nurse?
- Humana offers competitive benefits designed for whole-person well-being. These typically include medical, dental, and vision benefits, a 401(k) retirement savings plan, paid time off, company holidays, volunteer time off, paid parental and caregiver leave, short-term and long-term disability, and life insurance.