Utilization Management Registered Nurse
Humana · Arizona, United States
- Hybrid
- Full-time
- $97,800 / year
- Arizona, United States
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Job highlights
- Utilize RN skills for care coordination and benefit determinations.
- Manage post-acute care services for members.
- Interpret medical criteria and make care decisions.
- Communicate with providers and members for treatment.
- Work remotely with occasional travel required.
About the role
About the Role
Humana is seeking a Utilization Management Registered Nurse to join their caring community. In this role, you will use your 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 be a part 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 primary goal is to ensure members receive the appropriate level of care in the most appropriate setting.
Key Responsibilities
- Utilize clinical nursing skills to interpret and support medical services and benefit administration determinations.
- Make determinations based on established medical criteria and information provided by attending physicians and other care providers.
- Complete request determinations within established processing time frames (e.g., 10 reviews per day).
- Communicate with providers, members, and other parties to facilitate care and treatment.
- Contribute to delivering coordinated care for Humana members.
- Understand department, segment, and organizational strategy and operating goals.
Required Qualifications
- 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.
- 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, 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
For remote employees, a minimum download speed of 25 Mbps and an upload speed of 10 Mbps is required for internet service. Satellite, cellular, and microwave connections may be used with leadership approval. Employees in California, Illinois, Montana, or South Dakota will receive a bi-weekly internet expense payment. Humana will provide necessary telephone equipment. A dedicated, quiet workspace is required 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 Criteria Interpretation
- Care Coordination
- Provider Communication
- Patient Assessment
- Health Plan Operations
- Medical Necessity
- RN Experience
Skills & topics
- Utilization Management
- Registered Nurse
- RN
- Case Management
- Healthcare
- Clinical Nursing
- Home Health
- SNF
- DME
- Insurance
How to get hired
- Tailor your resume: Highlight your RN clinical experience, utilization management skills, and any experience with medical necessity criteria like Milliman or Interqual. Quantify achievements where possible.
- Craft a compelling application: Clearly articulate your passion for improving consumer experiences and your understanding of Humana's mission.
- Prepare for the interview: Be ready to discuss your clinical background, how you've made determinations based on criteria, and your experience in a remote, metrics-driven environment.
- Showcase your remote work readiness: Demonstrate your ability to work independently, manage your time effectively, and maintain a HIPAA-compliant workspace.
Technical preparation
Master RN clinical skills for accurate assessments.,Study Milliman Care Guidelines or Interqual.,Practice efficient documentation and communication.,Ensure reliable internet for remote work.
Behavioral questions
Describe a time you handled complex patient cases.,How do you prioritize multiple urgent tasks?,How do you communicate difficult decisions to patients?,Show your passion for improving consumer experiences.
Frequently asked questions
- What type of clinical experience is most valued for the Utilization Management Registered Nurse role at Humana?
- Humana highly values clinical experience as a Registered Nurse (RN) in settings such as hospitals, Skilled Nursing Facilities (SNF), Home Health, or acute care. Having over one year of this type of experience is a minimum requirement.
- Does Humana require specific certifications for the Utilization Management Registered Nurse position?
- Yes, a Compact Registered Nurse (RN) license in your state of residence is a mandatory requirement for this role. While not strictly required, preferred qualifications include knowledge of medical necessity criteria like Milliman Care Guidelines or Interqual.
- What are the technical requirements for the remote Utilization Management Registered Nurse role at Humana?
- For remote work, you'll need reliable internet service with a minimum download speed of 25 Mbps and an upload speed of 10 Mbps. A wired cable or DSL connection is suggested. Humana will provide the necessary telephone equipment.
- What is the typical workload for a Utilization Management Registered Nurse at Humana?
- The job description mentions completing request determinations within established processing time frames, giving an example of around 10 reviews per day. This indicates a metrics-focused role where efficiency and volume are key.
- What kind of career growth opportunities are available for a Utilization Management Registered Nurse at Humana?
- While specific growth paths aren't detailed, Humana's commitment to improving consumer experiences and its status as a leading U.S. healthcare company suggest opportunities for advancement within utilization management, care coordination, or other health plan roles.
- How does Humana support work-from-home employees in this Utilization Management RN role?
- Humana supports remote employees by providing necessary telephone equipment and offering a bi-weekly internet expense payment for those in specific states (California, Illinois, Montana, South Dakota). They also emphasize the importance of a dedicated, interruption-free workspace.
- What is the compensation for a Utilization Management Registered Nurse at Humana?
- The advertised pay range for this full-time position is $71,100 to $97,800 per year, and the role is eligible for a bonus incentive plan based on performance.