utilization management um nurse

Humana

<div>
 
 Become a part of our caring community
 
 
 
 The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
 
 
 
 As a Utilization Management Registered Nurse
 
 
 
 <ul>
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 You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
 </li>
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 Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
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 You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?)
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 You will communicate with providers, members, or other parties to facilitate care and treatment.
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 You will help deliver coordinated care for our members
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 You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
 
 
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 </ul>
 
 Required Qualifications
 
 
 
 
 Use your skills to make an impact
 
 
 
 <ul>
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 Must hold Compact Registered Nurse (RN) license in your state of residence
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 Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
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 Must be passionate about contributing to an organization focused on improving consumer experiences
 
 
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 </ul>
 
 Preferred Qualifications
 
 
 
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 Previous experience in utilization management/utilization review for a health plan or acute care setting
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 Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
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 Experience working in a fully remote, metrics-focused role
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 Experience as an MDS Coordinator or discharge planner in an acute care setting
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 Experience as an RN for a Medicare Certified Home Health agency
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 Health Plan or Medicare / Medicaid Experience
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 Call center or triage experience
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 BSN or bachelor's degree in a related field
 
 
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 </ul>
 Additional Information
 
 
 
 Work-at-Home Information
 
 
 
 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:
 
 
 <ul>
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 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.
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 Satellite, cellular and microwave connection can be used only if approved by leadership.
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 Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
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 Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
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 Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
 
 
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 </ul>
 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.
 
 
 
 Description Of Benefits
 
 
 
 Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) 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, volunteer time off, 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 &ndash; 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.
 
 
 
 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.
</div>

Utilization Management Registered Nurse

SSM Health

<div><div>It's more than a career, it's a calling.
MO-REMOTE
Worker Type:
Regular
Job Summary:
Serves as the Utilization Management system-wide point of coordination between regional clinical and operational team leaders, physician liaisons, and revenue cycle leaders.
Job Responsibilities and Requirements:
PRIMARY RESPONSIBILITIES<ul><li>
Serves as the direct resource for the regional physician liaisons regarding Utilization Management (UM) initiatives and regional specific UM issues.</li><li>
Performs audits on UM denial write off accounts to ensure accurate categorizing of the root cause of denial and to identify potential opportunities for claims re-bill.</li><li>
Collaborates with Managed Care Organization (MCO) team members to stay abreast of contractual updates to develop and maintain UM payer grids with contractual requirements.</li><li>
Serves as a UM subject matter expert on state and federal regulatory requirements related to UM processes.</li><li>
Represents the system UM team on committees and work groups as assigned by leadership.</li><li>
Presents critical messages and complex information and reports to UM leadership.</li><li>
Provides responses to questions and concerns raised by physician liaisons, clinical and operational team members, providers, and UM leaders.</li><li>
Supports UM leadership and collaborating teams and providers with resources, data, and education to improve UM outcomes.</li><li>
Applies the existing body of evidence-based practice and scientific knowledge in health care to medical-surgical nursing practice, ensuring that nursing care is delivered based on patient&rsquo;s age-specific needs and clinical needs as described in the department's Scope of Service.</li><li>
Performs other duties as assigned.</li></ul>
EDUCATION<ul><li>
Graduate of accredited school of nursing or education equivalency for licensing</li></ul>
EXPERIENCE<ul><li>
Two years' acute nursing experience, four years of Utilization Management experience</li></ul>
PHYSICAL REQUIREMENTS
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. 
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. 
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. 
Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. 
Frequent keyboard use/data entry. 
Occasional bending, stooping, kneeling, squatting, twisting and gripping. 
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. 
Rare climbing.
REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 
 
State of Work Location: Illinois<ul><li>
 Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)</li></ul> 
 
State of Work Location: Missouri<ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Missouri Division of Professional Registration</li></ul> 
 
State of Work Location: Oklahoma<ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)</li></ul> 
 
State of Work Location: Wisconsin<ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services</li></ul>
Work Shift:
Day Shift (United States of America)<div><div><div><div><div><div><div>
Job Type:</div></div></div></div></div></div></div>
Employee
Department:
8746030033 Sys Utilization Management
Scheduled Weekly Hours:
40
Benefits:
SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.<ul><li>
Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).</li><li>
Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.</li><li>
Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.</li></ul>
Explore All Benefits
SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.</div></div>

RN-Utilization Management and Denials Liaison

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