Remote Utilization Management Nurse - Care Coordination

Humana; South Carolina; Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Medical, dental & vision benefits

401(k) retirement savings plan

Paid time off & holidays

Job summary

Humana is seeking an experienced Utilization Management Registered Nurse to interpret and support coordination, documentation and communication of medical services and benefit determinations. You will work with providers, members, and care teams to ensure appropriate care in the right setting, in a remote capacity.

Ideal candidates have a compact RN license, 1+ year RN experience in hospital/SNF/home health, and knowledge of utilization management criteria.

Qualifications

• Must hold Compact RN license in state of residence.
• Over 1 year of clinical RN experience in hospital, SNF, Home Health, or acute care.
• Experience in utilization management/review for a health plan or acute care setting.
• Basic knowledge of Milliman Care Guidelines or InterQual.
• Experience working in a fully remote, metrics-focused role.
• Experience as an MDS Coordinator or discharge planner in an acute care setting.
• Experience as an RN for a Medicare Certified Home Health agency.
• Health Plan or Medicare/Medicaid Experience.
• Call center or triage experience.
• BSN or bachelor's degree in a related field.

Responsibilities

• Interpret and support the coordination, documentation and communication of medical services and benefit determinations.
• Communicate with providers, members and other parties to facilitate care and treatment.
• Help deliver coordinated care for members.

Skills

RN license

Clinical RN experience

Utilization management

Milliman Care Guidelines

InterQual

Remote/work-from-home experience

MDS Coordinator / discharge planning

Medicare/Medicaid experience

Call center / triage

BSN or bachelor's degree

Education

BSN or bachelor’s degree in a related field

Job description

Humana is seeking an experienced Utilization Management Registered Nurse to interpret and support coordination, documentation and communication of medical services and benefit determinations. You will work with providers, members, and care teams to ensure appropriate care in the right setting, in a remote capacity.

Ideal candidates have a compact RN license, 1+ year RN experience in hospital/SNF/home health, and knowledge of utilization management criteria.