[Hiring] Utilization Management Registered Nurse @Humana

Role Description

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. Work assignments are varied and frequently require interpretation, independent judgment, and determination of the appropriate course of action.

As a Utilization Management RN on the OneHome / Home Solutions UM Team, you will use your clinical knowledge, communication skills, and critical thinking to support value-based care for members. You will coordinate and communicate with providers, members, and other parties to facilitate appropriate member care and treatment.

Cross-Functional Role Expectation

This is a cross-functional Utilization Management nursing role. Although an associate may initially be aligned to Home Health UM, the associate is expected to develop and maintain the skills necessary to support utilization management across multiple levels of care. Based on evolving business, member, and operational needs, assignments may include cross-training and review of other levels of care within the scope of the nurse’s licensure, qualifications, completed training, and demonstrated competency. Primary team, workflow, schedule, or level-of-care assignments may change over time.

Primary Responsibilities

• Help ensure fully coordinated care for members through timely, accurate, and clinically appropriate utilization management review.
• Review clinical information and apply established guidelines, benefit requirements, policies, processes, and procedures.
• Communicate effectively with providers, members, and internal partners to support appropriate care and resolution of authorization needs.
• Document determinations and relevant clinical rationale accurately in designated systems.
• Manage assigned inventory and meet applicable quality, productivity, and turnaround-time expectations.
• Complete required cross-training and demonstrate competency in additional utilization management workflows or levels of care when assigned.
• Maintain flexibility to support changing team, workflow, and level-of-care assignments based on business needs.

Success in This Role Requires

• A passion for contributing to an organization focused on continuously improving consumer experiences.
• Excellent organizational and time-management skills.
• Solid analytical skills to understand and interpret clinical information and make recommendations that support appropriate member outcomes.
• Technical proficiency and the ability to navigate multiple systems and screens while working cases.
• Collaboration skills to interact effectively with multiple internal and external parties.
• An understanding of department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• The ability to make decisions regarding individual work methods, occasionally in ambiguous situations, with minimal direction and guidance when needed.
• The ability to follow established guidelines, processes, and procedures.
• Adaptability and willingness to cross-train and support multiple utilization management functions and levels of care as business needs evolve.
• The ability to successfully complete required training and demonstrate competency before independently reviewing an additional level of care.

Qualifications

• Minimum of an Associate Degree in Nursing.
• Current, unrestricted Registered Nurse (RN) license in a Nurse Licensure Compact state, with no disciplinary action.
• Valid multistate/compact license, or residence in a compact state with eligibility to obtain or upgrade to multistate licensure.
• Three or more years of progressive and varied clinical experience, including direct patient care for a geriatric population.
• Effective telephonic and virtual communication skills.
• Working knowledge of Microsoft Word, Outlook, and Excel.
• Ability to work independently under general instruction and collaboratively within a team.
• Ability to obtain and maintain additional state licensure if required to support assigned business needs.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN).
• Two or more years of Home Health, utilization management, or other relevant level-of-care experience.
• Experience in a managed care or health plan setting.
• Experience reviewing more than one level of care, such as Home Health, skilled nursing facility, inpatient, or outpatient services.
• Experience using CGX or another authorization management platform.

Work-at-Home Requirements

• Ability to provide a high-speed DSL or cable modem connection for a home office. Satellite and wireless internet service are not permitted for this role.
• Minimum internet speed of 25 Mbps download and 10 Mbps upload for optimal performance.
• Ability to verify internet speed using an approved internet speed test.
• A dedicated office space without ongoing interruptions to support productivity expectations and protect member PHI and HIPAA information.
• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$71,100 - $97,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Benefits

• Medical, dental and vision benefits.
• 401(k) retirement savings plan.
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance.
• Many other opportunities.

Company Description

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it.

These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large.