Utilization Management Registered Nurse

This is a fully remote position, open to applicants in Alabama, +32 more states.

📋 Description

• Interpret and assist with the coordination, documentation, and communication regarding medical services and benefit administration decisions.

• Utilize established medical criteria alongside information from attending physicians and other healthcare providers to make informed determinations.

• Ensure that request determinations are completed within the designated processing timelines.

• Engage with providers, members, and other stakeholders to facilitate care and treatment.

• Contribute to the delivery of coordinated care for members.

• Provide support for post-acute care services, including Skilled Nursing Facilities, Home Health, and Durable Medical Equipment.

• Comprehend departmental, segment, and organizational strategies as well as operational objectives.

• Report to the Manager of Utilization Management as part of the One Home/Home Solutions Utilization Management team.

⛳️ Requirements

• Must possess a Compact Registered Nurse (RN) license in your state of residence.

• Over one year of clinical experience as an RN in a hospital, Skilled Nursing Facility, Home Health, or acute care environment.

• A strong passion for contributing to an organization dedicated to enhancing consumer experiences.

• Minimum internet speed of 25 Mbps for download and 10 Mbps for upload.

• A dedicated workspace free from interruptions to safeguard member PHI/HIPAA information.

• Must fulfill Florida Level 2 background screening requirements when applying from a Florida work location.

• Preferred: Previous experience in utilization management or utilization review within a health plan or acute care setting.

• Preferred: Basic understanding of medical necessity criteria such as Milliman Care Guidelines or InterQual.

• Preferred: Experience in a fully remote role with a focus on metrics.

• Preferred: Background 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: Familiarity with Health Plan or Medicare/Medicaid environments.

• Preferred: Experience in a call center or triage capacity.

• Preferred: Bachelor of Science in Nursing (BSN) or a degree in a related field.

🏝️ Benefits

• Bonus incentive plan based on both company and individual performance.

• Comprehensive medical, dental, and vision benefits.

• 401(k) retirement savings plan.

• Paid time off.

• Company and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability coverage.

• Life insurance.

• Internet expense reimbursement for employees working from home in California, Illinois, Montana, or South Dakota.

• Telephone equipment that meets business requirements.

• Flexible remote work arrangement.

• Occasional travel to Humana offices for training or meetings.