Utilization Management Registered Nurse
Humana · Florida, United States
- Hybrid
- Full-time
- $84,000 / year
- Florida, United States
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Job highlights
- Utilize RN skills for medical service coordination.
- Interpret criteria and make care determinations.
- Communicate with providers and members.
- Work remotely with occasional office travel.
- Focus on post-acute care for members.
About the role
About the Role
Join our caring community as a Utilization Management Registered Nurse (RN) at Humana. In this role, you will leverage your clinical nursing skills to interpret, coordinate, document, and communicate medical services and benefit administration determinations. You will report to the Manager of Utilization Management and be a vital part of the One Home/Home Solutions Utilization Management team, which oversees post-acute care services including Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). Our primary goal is to ensure members receive the appropriate level of care in the most suitable setting.
What You Will Do
- Utilize clinical nursing expertise to interpret and support medical service coordination and benefit administration.
- Make determinations based on established medical criteria and information from attending physicians and other care providers.
- Complete request determinations within established processing time frames, aiming for approximately 10 reviews per day.
- Communicate effectively with providers, members, and other stakeholders to facilitate care and treatment.
- Contribute to delivering coordinated care for our members.
- Understand and align with department, segment, and organizational strategy and operating goals.
Required Qualifications
- Hold a Compact Registered Nurse (RN) license in your state of residence.
- Possess greater than one year of clinical experience as an RN in a hospital, SNF, Home Health, or acute care setting.
- Demonstrate 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 (e.g., Milliman Care Guidelines or Interqual).
- Experience 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
- Internet Requirements: Minimum download speed of 25 Mbps and upload speed of 10 Mbps is required. Wireless, wired cable, or DSL connection suggested. Satellite, cellular, and microwave connections require leadership approval.
- Internet Expense Reimbursement: Employees in California, Illinois, Montana, or South Dakota will receive a bi-weekly internet expense payment.
- Equipment: Humana will provide necessary telephone equipment.
- Work Environment: Maintain a dedicated, interruption-free workspace to protect member PHI / HIPAA information.
Travel
Occasional travel to Humana's offices for training or meetings may be required, despite this being a remote position.
Key skills/competency
- Utilization Management Registered Nurse
- Clinical Nursing Skills
- Medical Services Coordination
- Benefit Administration
- Provider Communication
- Member Care Facilitation
- Acute Care Experience
- Healthcare Criteria Interpretation
- RN License
- Post-Acute Care Management
Skills & topics
- Utilization Management
- Registered Nurse
- RN
- Case Management
- Healthcare
- Insurance
- Home Health
- SNF
- DME
- Clinical Review
How to get hired
- Tailor your resume: Highlight your RN clinical experience in hospital, SNF, or home health settings, and any utilization review experience.
- Showcase your skills: Emphasize your understanding of medical necessity criteria and your ability to coordinate care and communicate with providers.
- Address remote work: Mention your experience in metrics-focused, remote roles and your ability to maintain a dedicated workspace.
- Prepare for the interview: Be ready to discuss your clinical judgment, problem-solving abilities, and your passion for improving consumer health experiences at Humana.
- Understand the culture: Research Humana's mission and values, focusing on their commitment to caring communities and improving member health outcomes.
Technical preparation
Review clinical nursing standards.,Study medical necessity criteria.,Practice efficient documentation skills.,Familiarize with EMR/EHR systems.
Behavioral questions
How do you handle competing priorities?,Describe a challenging patient case.,How do you ensure patient privacy (HIPAA)?,Why Humana's mission resonates with you?
Frequently asked questions
- What are the primary responsibilities of a Utilization Management Registered Nurse at Humana?
- The primary responsibilities include using clinical nursing skills to interpret and coordinate medical services, make determinations based on medical criteria, communicate with providers and members, and ensure members receive appropriate care in the right setting. This role focuses on post-acute care services.
- What is the required clinical experience for this Utilization Management RN position?
- You need 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.
- Is this a remote position, and what are the internet requirements for the Utilization Management RN role?
- Yes, this is a remote position. You will need a reliable internet connection with at least 25 Mbps download and 10 Mbps upload speeds. Specific connection types are suggested, and satellite/cellular/microwave require leadership approval.
- What kind of medical necessity criteria knowledge is preferred for the Utilization Management Registered Nurse job?
- Preferred candidates have basic knowledge of medical necessity criteria, such as Milliman Care Guidelines or Interqual, which are used to make care determinations.
- How does Humana support remote employees in this Utilization Management RN role?
- Humana provides necessary telephone equipment and offers bi-weekly internet expense payments for employees in specific states (California, Illinois, Montana, South Dakota). Employees are also expected to maintain a dedicated, interruption-free workspace.
- What is the typical workload for a Utilization Management Registered Nurse regarding daily reviews?
- The job description indicates a target of completing request determinations within established processing time frames, with an example suggesting approximately 10 reviews per day.
- Does Humana offer opportunities for professional development for Utilization Management RNs?
- While not explicitly detailed for this specific role, Humana offers competitive benefits that support whole-person well-being and encourages smart healthcare decisions. The company's focus on growth and improving consumer experiences suggests potential for development.
- What is the compensation range for the Utilization Management Registered Nurse position at Humana?