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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and clinical nursing, with a focus on improving consumer experiences and coordinating care. Holds a Compact Registered Nurse (RN) license and possesses experience in acute care settings, skilled nursing facilities, and home health.
Highest-signal resume keywords
Compact Registered Nurse (RN) LicenseUtilization Management ExperienceClinical Experience in Acute CareKnowledge of Medical Necessity CriteriaExperience in Home Health Care
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical NursingUtilization ManagementMedical DocumentationCare CoordinationPatient CommunicationMedical Necessity CriteriaDischarge PlanningMetrics-Focused PerformanceBackground Screening CompliancePHI/HIPAA Compliance
Soft Skills
Interpersonal CommunicationOrganizational SkillsProblem-SolvingTeam CollaborationPassion for Consumer Experience
Certifications & Qualifications
Compact Registered Nurse (RN) License
Industry Keywords
Skilled Nursing FacilityHome HealthDurable Medical EquipmentMedicare Certified Home HealthHealth PlanMedicaidCall Center ExperienceTriage ExperienceFlorida Level 2 Background ScreeningMilliman Care Guidelines
About the role
Key responsibilities & impact- Interpret and support the coordination, documentation, and communication of medical services and benefit administration determinations
- Use established medical criteria and information from attending physicians and other care providers to make determinations
- Complete request determinations within established processing time frames
- Communicate with providers, members, and other parties to facilitate care and treatment
- Help deliver coordinated care for members
- Support post-acute care services including Skilled Nursing Facility, Home Health, and Durable Medical Equipment
- Understand department, segment, and organizational strategy and operating goals
- Report to the Manager of Utilization Management as part of the One Home/Home Solutions Utilization Management team
Requirements
What you’ll need- Must hold Compact Registered Nurse (RN) license in your state of residence
- Greater than one year of clinical experience as an RN in a hospital, SNF, Home Health, or acute care setting
- Must be passionate about contributing to an organization focused on improving consumer experiences
- Minimum internet speed of 25 Mbps download and 10 Mbps upload
- Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information
- Must meet Florida Level 2 background screening requirements when applying from a Florida work location
- Preferred: Previous experience in utilization management/utilization review for a health plan or acute care setting
- Preferred: Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or InterQual
- Preferred: Experience working in a fully remote, metrics-focused role
- Preferred: Experience as an MDS Coordinator or discharge planner in an acute care setting
- Preferred: Experience as an RN for a Medicare Certified Home Health agency
- Preferred: Health Plan or Medicare/Medicaid experience
- Preferred: Call center or triage experience
- Preferred: BSN or bachelor's degree in a related field
Benefits
Comp & perks- Bonus incentive plan based on company and/or individual performance
- Medical, dental and vision benefits
- 401(k) retirement savings plan
- Paid time off
- Company and personal holidays
- Paid parental and caregiver leave
- Short-term and long-term disability
- Life insurance
- Internet expense payment for employees working from home in California, Illinois, Montana, or South Dakota
- Telephone equipment appropriate to business requirements
- Remote work arrangement
- Occasional travel to Humana offices for training or meetings