Utilization Management Registered Nurse
Humana · Tennessee, United States
- Hybrid
- Full-time
- $97,800 / year
- Tennessee, United States
Job highlights
- RN role coordinating post-acute care services.
- Interpret medical criteria for benefit determinations.
- Remote position with dedicated workspace required.
- Competitive salary, bonus, and benefits offered.
- Contribute to improving member health outcomes.
About the role
About the Role
Humana is seeking a Utilization Management Registered Nurse to join our caring community. 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 an integral part of the One Home/Home Solutions Utilization Management team, which focuses on post-acute care services such as Skilled Nursing Facilities (SNF), Home Health, and Durable Medical Equipment (DME). Our primary goal is to ensure members receive the appropriate level of care in the most appropriate setting.
Key Responsibilities
- Utilize clinical nursing expertise to interpret and support medical service coordination, documentation, and benefit administration determinations.
- Make determinations based on established medical criteria, using information provided by 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 parties to facilitate care and treatment.
- Contribute to delivering coordinated care for our members.
- Understand department, segment, and organizational strategy and operating goals, and their linkages to related areas.
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 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 effective remote work, your self-provided internet service must meet the following criteria: a minimum download speed of 25 Mbps and an upload speed of 10 Mbps is required. Wireless, wired cable, or DSL connections are suggested. Satellite, cellular, and microwave connections may be used only if approved by leadership. Employees in California, Illinois, Montana, or South Dakota will receive a bi-weekly payment for internet expenses. Humana will provide necessary telephone equipment. You must work from a dedicated space that lacks 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 hours per week.
Pay Range
The annual base pay range for this position is $71,100 - $97,800. Individual pay will vary based on demonstrated job-related skills, knowledge, experience, education, and certifications. This role is eligible for a bonus incentive plan based on company and/or individual performance.
Benefits
Humana offers competitive benefits for whole-person well-being, including medical, dental, vision, 401(k) retirement savings, paid time off, company holidays, volunteer time off, paid parental and caregiver leave, short-term and long-term disability, and life insurance.
About Humana
Humana Inc. is a leading U.S. healthcare company. Through our insurance services and CenterWell healthcare services, we help millions achieve their best health by delivering the care and service they need, when they need it. Learn more at Humana.com and CenterWell.com.
Key skills/competency
Utilization Management Registered Nurse, clinical nursing skills, medical services, benefit administration, post-acute care, Skilled Nursing Facility (SNF), Home Health, Durable Medical Equipment (DME), medical criteria, care coordination, provider communication, member advocacy, health plan operations, remote work.
Skills & topics
- Utilization Management
- Registered Nurse
- RN
- Utilization Review
- Case Management
- Healthcare
- Clinical Nurse
- Post-Acute Care
- Home Health
- Skilled Nursing Facility
How to get hired
- Tailor your resume: Highlight your RN clinical experience in hospital, SNF, Home Health, or acute care settings, and any utilization review or management experience.
- Showcase soft skills: Emphasize your communication abilities with providers and members, and your passion for improving consumer experiences.
- Understand the role: Familiarize yourself with medical necessity criteria like Milliman Care Guidelines or Interqual if you have that experience.
- Prepare for remote work: Ensure your home office setup meets the technical requirements and you have a dedicated, interruption-free space.
- Ace the interview: Be ready to discuss your clinical background and how you've managed complex patient cases and collaborated with care teams.
Technical preparation
Behavioral questions
Frequently asked questions
- What is the work arrangement for the Utilization Management Registered Nurse position at Humana?
- This Utilization Management Registered Nurse position at Humana is primarily a remote role. While you will work from home, occasional travel to Humana's offices for training or meetings may be required.
- What are the technical requirements for the remote work aspect of this Humana RN job?
- For remote work, your internet service must meet specific criteria: at least 25 Mbps download and 10 Mbps upload speed. Wired cable or DSL is suggested. Satellite, cellular, and microwave connections require leadership approval. You also need a dedicated, quiet workspace to protect member information.
- What specific clinical experience is required for the Utilization Management Registered Nurse role at Humana?
- Humana requires 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 for this role.
- Does Humana offer benefits for the Utilization Management Registered Nurse position?
- Yes, Humana offers competitive benefits designed to support whole-person well-being, including medical, dental, vision benefits, a 401(k) retirement savings plan, various paid time off options, disability insurance, and life insurance.
- What is the expected workload or productivity for a Utilization Management Registered Nurse at Humana?
- The job description mentions completing request determinations within established processing time frames, with an example of approximately 10 reviews per day. This indicates a metrics-focused aspect to the role.
- What kind of medical necessity criteria might I encounter as a Utilization Management Registered Nurse at Humana?
- Preferred qualifications include basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual. Familiarity with these tools will be beneficial for assessing the appropriateness of care.
- Is a BSN degree required for the Utilization Management Registered Nurse role at Humana?
- A BSN or bachelor's degree in a related field is listed as a preferred qualification, not a strict requirement. Your RN license and clinical experience are the primary requirements.
- What is the salary range for the Utilization Management Registered Nurse position at Humana?