Utilization Management Registered Nurse

This is a fully remote position, open to applicants in Alabama, +4 more states.

📋 Description

• Interpret and assist with the coordination, documentation, and communication related to medical services and benefit administration decisions

• Make decisions based on established medical criteria and information provided by attending physicians and other healthcare providers

• Complete request determinations within the set processing timeframes

• Communicate effectively with providers, members, and other stakeholders to facilitate care and treatment

• Aid in delivering coordinated care for members

• Support post-acute care services, including Skilled Nursing Facilities, Home Health, and Durable Medical Equipment

• Contribute to the department's, segment's, and organization's strategic and operational objectives

• Report directly to the Manager of Utilization Management as a 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 desire to contribute to an organization dedicated to enhancing consumer experiences

• Personal internet service with a minimum of 25 Mbps download and 10 Mbps upload speeds

• Suggested connection types include wireless, wired cable, or DSL; satellite, cellular, or microwave connections require leadership approval

• Capability to work from a designated space without ongoing interruptions to safeguard member PHI/HIPAA information

• Preferred: prior 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, metrics-driven role

• Preferred: background as an MDS Coordinator or discharge planner in an acute care environment

• Preferred: experience as an RN for a Medicare Certified Home Health agency

• Preferred: background in Health Plan or Medicare/Medicaid

• Preferred: experience in call center or triage roles

• Preferred: BSN or a bachelor's degree in a related discipline

🏝️ 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 reimbursement for employees residing and working from home in California, Illinois, Montana, or South Dakota

• Telephone equipment suitable for business requirements

• Flexible work arrangement from home