Utilization Management Registered Nurse
Humana · Pennsylvania, United States
- Hybrid
- Full-time
- $84,450 / year
- Pennsylvania, United States
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Job highlights
- RN role utilizing clinical skills for medical determinations.
- Coordinate care for SNF, Home Health, and DME services.
- Interpret medical criteria and communicate with providers.
- Remote position with occasional office travel required.
- Competitive salary, bonus, and comprehensive benefits.
About the role
About the Role
Become a part of our caring community as a Utilization Management Registered Nurse. 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 serve as a member of the One Home/Home Solutions Utilization Management team, managing post-acute care services including Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). Our team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
Responsibilities
- Interpret and support the coordination, documentation, and communication of medical services and benefit administration determinations using clinical nursing skills.
- Make determinations based on information provided by the attending physician and other care providers, using established medical criteria.
- 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 members.
- Understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
Required Qualifications
Use your skills to make an impact:
- 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
- Minimum download speed of 25 Mbps and upload speed of 10 Mbps required for self-provided internet service.
- Wireless, wired cable, or DSL connection suggested. Satellite, cellular, and microwave connections may be used if approved by leadership.
- Employees in California, Illinois, Montana, or South Dakota will receive a bi-weekly internet expense payment.
- Humana will provide appropriate telephone equipment.
- Work from a dedicated, quiet space 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
$71,100 - $97,800 per year
Bonus Incentive Plan
This job is eligible for a bonus incentive plan based on company and/or individual performance.
Benefits
Humana offers competitive benefits supporting whole-person well-being, including medical, dental, and vision benefits, 401(k) retirement savings plan, time off, disability insurance, life insurance, and more.
About Us
Humana Inc. is a leading U.S. healthcare company focused on making it easier for millions to achieve their best health through its insurance services and healthcare services. Learn more at Humana.com and CenterWell.com.
Key skills/competency
- Utilization Management Registered Nurse
- Clinical Nursing Skills
- Medical Criteria Interpretation
- Care Coordination
- Benefit Administration
- Provider Communication
- Health Plan Experience
- Home Health
- Skilled Nursing Facility (SNF)
- Durable Medical Equipment (DME)
Skills & topics
- Utilization Management
- Registered Nurse
- RN
- Case Management
- Healthcare
- Clinical Review
- Health Insurance
- Remote Work
- Home Health
- SNF
How to get hired
- Tailor your resume: Highlight your RN clinical experience in hospital, SNF, or Home Health settings, and any utilization review or health plan experience.
- Address remote work requirements: Clearly state your ability to meet internet speed requirements and your experience in remote, metrics-focused roles.
- Showcase relevant skills: Emphasize your knowledge of medical necessity criteria (Milliman, Interqual) and your passion for improving consumer experiences.
- Prepare for behavioral questions: Be ready to discuss how you handle high-volume review tasks and coordinate care effectively.
- Network and apply: Connect with Humana recruiters on LinkedIn and submit your application through their careers portal.
Technical preparation
Master medical necessity criteria (Milliman, Interqual).,Practice efficient documentation and review workflows.,Familiarize with EHR and claims processing systems.,Understand HIPAA and data privacy regulations.
Behavioral questions
Describe handling high-volume review tasks daily.,How do you ensure accurate care coordination?,Tell me about a time you communicated with a difficult provider.,How do you stay updated on medical criteria?
Frequently asked questions
- What is the primary responsibility of a Utilization Management Registered Nurse at Humana?
- The primary responsibility of a Utilization Management Registered Nurse at Humana is to use clinical nursing skills to interpret and support the coordination, documentation, and communication of medical services and benefit administration determinations, ensuring members receive appropriate care.
- What clinical experience is required for the Utilization Management Registered Nurse role at Humana?
- The role requires greater than one year of clinical experience as an RN in a hospital, Skilled Nursing Facility (SNF), Home Health, or acute care setting.
- Is the Utilization Management Registered Nurse position at Humana fully remote?
- Yes, this is a remote position. However, occasional travel to Humana's offices for training or meetings may be required.
- What are the internet speed requirements for remote employees at Humana?
- Humana requires a minimum download speed of 25 Mbps and an upload speed of 10 Mbps for self-provided internet service. Specific connection types are suggested, and some alternatives may be approved by leadership.
- What is the salary range for the Utilization Management Registered Nurse position at Humana?
- The salary range for this position is $71,100 - $97,800 per year, with eligibility for a bonus incentive plan.
- Does Humana provide any support for remote employees regarding internet expenses?
- Yes, employees who live and work from home in California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
- What are the preferred qualifications for a Utilization Management Registered Nurse at Humana?
- Preferred qualifications include previous experience in utilization management/review, basic knowledge of medical necessity criteria, experience in a remote, metrics-focused role, experience as an MDS Coordinator or discharge planner, and health plan or Medicare/Medicaid experience.
- How does Humana support the well-being of its associates?
- Humana offers competitive benefits that support whole-person well-being, including medical, dental, and vision benefits, a 401(k) retirement savings plan, generous time off, disability and life insurance, and more.