Utilization Management Registered Nurse

Humana•Washington, DC

3d•$71,100 - $97,800•Remote

About The Position

The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation, and communication of medical services and benefit administration determinations. The role is 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 aims to ensure members receive the appropriate level of care in the most appropriate setting. The position uses established medical criteria to make determinations based on information from attending physicians and other care providers, completes determinations within established processing time frames, and communicates with providers, members, and other parties to facilitate care and treatment. The role supports coordinated member care and requires an understanding of department, segment, and organizational strategies and operating goals and how they relate to other areas. This is a remote position. Occasional travel to Humana offices for training or meetings may be required. Employees must work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information. Home-based employees must have internet service with at least 25 Mbps download and 10 Mbps upload; wireless, wired cable, or DSL is suggested. Satellite, cellular, and microwave connections require leadership approval. Humana provides appropriate telephone equipment, and employees in California, Illinois, Montana, or South Dakota who work from home receive a bi-weekly internet expense payment. The position is scheduled for 40 hours per week. The stated annual starting base pay range is $71,100 to $97,800, and the role is eligible for a bonus incentive plan based on company and/or individual performance.

Requirements

Hold a Compact Registered Nurse (RN) license in the state of residence.
Have more than one year of clinical RN experience in a hospital, SNF, Home Health, or acute care setting.
Be passionate about contributing to an organization focused on improving consumer experiences.

Nice To Haves

Previous utilization management or utilization review experience 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.

Responsibilities

Use clinical nursing skills to interpret and support the coordination, documentation, and communication of medical services and benefit administration determinations.
Make determinations using established medical criteria and information provided by attending physicians and other care providers.
Complete request determinations within established processing time frames.
Communicate with providers, members, and other parties to facilitate care and treatment.
Help deliver coordinated care for members.
Understand department, segment, and organizational strategy and operating goals, including their links to related areas.

Benefits

Medical, dental, and vision benefits.
401(k) retirement savings plan.
Paid time off, company holidays, and personal holidays.
Paid parental and caregiver leave.
Short-term and long-term disability benefits.
Life insurance.
Other opportunities supporting personal wellness and healthcare decisions.
Bonus incentive plan based on company and/or individual performance.
Bi-weekly internet expense payment for eligible home-based employees in California, Illinois, Montana, or South Dakota.
Telephone equipment appropriate to the position's business requirements.