Utilization Management Registered Nurse
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Job Description
Utilization Management RN coordinating medical-necessity determinations for Humana, a U.S. healthcare and insurance company. Supporting post-acute care across skilled nursing, home health, and durable medical equipment services.
Responsibilities:
- Interpret and support the coordination, documentation, and communication of medical services and benefit administration determinations
- Make determinations using established medical criteria and information from 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
- Support post-acute care services including Skilled Nursing Facility, Home Health, and Durable Medical Equipment
- Contribute to department, segment, and organizational strategy and operating goals
- Report to the Manager of Utilization Management as a member of the One Home/Home Solutions Utilization Management team
Requirements:
- Must hold a Compact Registered Nurse (RN) license in your state of residence
- More 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
- Self-provided internet service with at least 25 Mbps download and 10 Mbps upload speeds
- Wireless, wired cable, or DSL connection suggested; satellite, cellular, or microwave connection requires leadership approval
- Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information
- Preferred: previous utilization management/utilization review experience for a health plan or acute care setting
- Preferred: basic knowledge of medical necessity criteria such as Milliman Care Guidelines or InterQual
- Preferred: experience in a fully remote, metrics-focused role
- Preferred: experience as an MDS Coordinator or discharge planner in an acute care setting
- Preferred: experience as an RN for a Medicare Certified Home Health agency
- Preferred: Health Plan or Medicare/Medicaid experience
- Preferred: call center or triage experience
- Preferred: BSN or bachelor's degree in a related field
Benefits:
- Bonus incentive plan
- Medical benefits
- Dental benefits
- Vision benefits
- 401(k) retirement savings plan
- Paid time off
- Company holidays
- Personal holidays
- Paid parental leave
- Paid caregiver leave
- Short-term disability
- Long-term disability
- Life insurance
- Internet expense payment for employees who live and work from Home in California, Illinois, Montana, or South Dakota
- Telephone equipment appropriate to business requirements
- Flexible work arrangement from home
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