utilization review 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>
 <li>
 You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
 </li>
 <li>
 Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
 </li>
 <li>
 You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?)
 </li>
 <li>
 You will communicate with providers, members, or other parties to facilitate care and treatment.
 </li>
 <li>
 You will help deliver coordinated care for our members
 </li>
 <li>
 You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 
 Use your skills to make an impact
 
 
 
 <ul>
 <li>
 Must hold Compact Registered Nurse (RN) license in your state of residence
 </li>
 <li>
 Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
 </li>
 <li>
 Must be passionate about contributing to an organization focused on improving consumer experiences
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Previous experience in utilization management/utilization review for a health plan or acute care setting
 </li>
 <li>
 Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
 </li>
 <li>
 Experience working in a fully remote, metrics-focused role
 </li>
 <li>
 Experience as an MDS Coordinator or discharge planner in an acute care setting
 </li>
 <li>
 Experience as an RN for a Medicare Certified Home Health agency
 </li>
 <li>
 Health Plan or Medicare / Medicaid Experience
 </li>
 <li>
 Call center or triage experience
 </li>
 <li>
 BSN or bachelor's degree in a related field
 
 
 </li>
 </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>
 <li>
 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.
 </li>
 <li>
 Satellite, cellular and microwave connection can be used only if approved by leadership.
 </li>
 <li>
 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.
 </li>
 <li>
 Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
 </li>
 <li>
 Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
 
 
 </li>
 </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

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
Position Summary
This is a remote work from home role anywhere in the US with virtual training.
American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.
Key Responsibilities<ul><li>
This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients.</li><li>
Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures and regulatory standards while assessing benefits and/or member&rsquo;s needs to ensure appropriate administration of benefits.</li><li>
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues.</li><li>
Assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.</li><li>
Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management.</li><li>
Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.</li><li>
Utilizes case management processes in compliance with regulatory and company policies and procedures.</li><li>
Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations.</li><li>
Identifies and escalates member&rsquo;s needs appropriately following set guidelines and protocols.</li><li>
Need to actively reach out to members to collaborate/guide their care.</li><li>
Perform medical necessity reviews.</li></ul> 
Required Qualifications<ul><li>
5+ years&rsquo; experience as a Registered Nurse with at least 1 year of experience in a hospital setting.</li><li>
The AHH RN Case manager position requires the nurse to support members across multiple states. A RN who resides in a compact state is required to have an active multistate license through the Nurse Licensure Compact (NLC), allowing practice across participating states with one license. Nurses residing in non‑compact states must hold an individual, state‑specific RN license for each state they support.</li><li>
1+ years&rsquo; experience documenting electronically using a keyboard.</li><li>
1+ years&rsquo; current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/ Obstetrics experience.</li></ul> 
Preferred Qualifications<ul><li>
1+ years&rsquo; Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience as well as experience with transferring patients to lower levels of care.</li><li>
1+ years' experience in Utilization Review.</li><li>
CCM and/or other URAC recognized accreditation preferred.</li><li>
1+ years&rsquo; experience with MCG, NCCN and/or Lexicomp.</li><li>
Bilingual in Spanish preferred.</li></ul> 
Education<ul><li>
Diploma or Associates Degree in Nursing required.</li><li>
BSN preferred.</li></ul>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$54,095.00 - $155,538.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Case Manager, Registered Nurse

Search 5493+ Utilization review nurse jobs near you this June. New roles added regularly across leading industries. Apply today.

5493 utilization review nurse jobs Near Me

Utilization Management Registered Nurse

Utilization Management Registered Nurse

Utilization Management Registered Nurse

Utilization Management Registered Nurse

Case Manager, Registered Nurse

Utilization Management Registered Nurse

Utilization Management Registered Nurse