Utilization Management Registered Nurse - Home Health

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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.

Use your skills to make an impact

Required 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.
• Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
• Florida Background Screening Requirements: Notice for candidates applying to this position from a Florida work location, including Florida home-based work location. This position is subject to Florida Level 2 background screening through the Care Provider Background Screening Clearinghouse. For information about the screening process and requirements, visit: https://info.flclearinghouse.com.
• 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.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work.

Among our benefits, Humana provides 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 and many other opportunities.

About us

About Humana: 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. Learn more about what we offer at Humana.com and at CenterWell.com.

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Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.

It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.

This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.