Utilization Management Registered Nurse
Humana · Texas, United States
- Hybrid
- Full-time
- $84,450 / year
- Texas, United States
Tailored resume — keyword-matched to this role.
Hiring manager — we find who's hiring.
Intro email — drafted to reach them directly.
Job highlights
- Manage post-acute care services utilization.
- Interpret and coordinate medical services.
- Make determinations using medical criteria.
- Communicate with providers and members.
- Work remotely with occasional travel.
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 part of the One Home/Home Solutions Utilization Management team, which focuses on post-acute care services like 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 appropriate setting.
Responsibilities
- Utilize clinical nursing skills to interpret and support coordination, documentation, and communication of medical services 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 (e.g., 10 reviews per day).
- Communicate 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
- 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 is required for self-provided internet service.
- Wireless, wired cable, or DSL connection is 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 internet expense payment.
- Humana will provide necessary telephone equipment.
- Maintain a dedicated workspace free from 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
Pay Range
$71,100 - $97,800 per year
Additional Information
This job is eligible for a bonus incentive plan based on company and/or individual performance.
Benefits
Humana offers competitive benefits including medical, dental, and vision benefits, 401(k) retirement savings plan, time off, disability insurance, life insurance, and more.
About Humana
Humana Inc. is a leading U.S. healthcare company focused on making it easier for millions to achieve their best health through insurance services and healthcare services.
Key skills/competency
- Utilization Management Registered Nurse
- Clinical Nursing Skills
- Medical Services Coordination
- Benefit Administration Determinations
- Registered Nurse
- Acute Care
- Home Health
- Skilled Nursing Facility
- Medical Necessity Criteria
- Health Plan Experience
Skills & topics
- Utilization Management
- Registered Nurse
- RN
- Clinical Nursing
- Healthcare
- Post-Acute Care
- Home Health
- SNF
- DME
- Medical Necessity
- Utilization Review
- Health Plan
- Acute Care
- Remote Work
- Humana
How to get hired
- Tailor your resume: Highlight your RN clinical experience, especially in hospital, SNF, Home Health, or acute care settings, and any utilization review experience.
- Showcase your passion: Emphasize your commitment to improving consumer experiences and understanding of healthcare needs.
- Address remote work requirements: Confirm your internet speed and dedicated workspace meet Humana's work-at-home criteria.
- Prepare for the interview: Be ready to discuss your experience with medical necessity criteria and your approach to provider/member communication.
- Apply strategically: Clearly articulate how your skills align with Humana's mission and the specific requirements of the Utilization Management Registered Nurse role.
Technical preparation
Master RN clinical skills for reviews.,Study medical necessity criteria thoroughly.,Practice efficient daily review completion.,Understand HIPAA for member data.
Behavioral questions
Demonstrate empathy in member interactions.,Showcase problem-solving in complex cases.,Explain your time management skills.,Describe teamwork in a remote setting.
Frequently asked questions
- What are the primary responsibilities of a Utilization Management Registered Nurse at Humana?
- The Utilization Management Registered Nurse at Humana uses clinical nursing skills to coordinate, document, and communicate medical services and benefit determinations. This involves interpreting medical information, applying established criteria, making determinations within processing timeframes, and communicating with providers and members to facilitate appropriate care in the most suitable setting, particularly for post-acute services.
- What clinical experience is required for the Utilization Management Registered Nurse position at Humana?
- To be considered for the Utilization Management Registered Nurse role at Humana, candidates must possess over one year of clinical experience as a Registered Nurse (RN) in settings such as a hospital, Skilled Nursing Facility (SNF), Home Health, or another acute care environment. Holding a Compact RN license in your state of residence is also mandatory.
- Is this a remote position, and what are the technical requirements for remote work at Humana?
- Yes, this is a remote position. For effective remote work, Humana requires a minimum internet download speed of 25 Mbps and an upload speed of 10 Mbps, preferably via wired cable or DSL. Specific states may receive internet expense reimbursement. You must also maintain a dedicated, interruption-free workspace to protect member information.
- What is the typical pay range for a Utilization Management Registered Nurse at Humana?
- The estimated annual salary range for a full-time Utilization Management Registered Nurse at Humana is between $71,100 and $97,800. This range can vary based on factors like geographic location, demonstrated skills, knowledge, experience, education, and certifications. The position is also eligible for a bonus incentive plan.
- Does Humana offer benefits for the Utilization Management Registered Nurse role?
- Yes, Humana provides a comprehensive benefits package designed to support employee well-being. This includes medical, dental, and vision insurance, a 401(k) retirement savings plan, paid time off, disability and life insurance, and other opportunities for personal and family wellness.
- What kind of experience is considered preferred for the Utilization Management Registered Nurse role at Humana?
- Preferred qualifications for this role include previous experience in utilization management or utilization review for a health plan or acute care setting, basic knowledge of medical necessity criteria (like Milliman Care Guidelines or Interqual), experience in a remote, metrics-focused role, and experience as an MDS Coordinator or discharge planner.