Utilization Management Registered Nurse

🔥 0 minutes ago

🏈 Alabama, New Jersey, +3 more states – Remote

🏈 Alabama – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote

💵 $71.1k - $97.8k / year

⏰ Full Time

🟢 Junior

🚫👨‍🎓 No degree required

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• 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