Remote Utilization Management Nurse (RN)

Humana; Montana; Remote; USD 71,000 - 98,000; Full time

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and support coordination, documentation and benefit determinations for post-acute care services (SNF, Home Health, DME). You will report to the Manager of Utilization Management and work within the One Home/Home Solutions team.

This remote role requires compact RN license in your state, hospital/SNF/Home Health RN experience, and knowledge of criteria such as Milliman Care Guidelines or InterQual.

Qualifications

• Must hold Compact RN license in your state of residence.
• Greater than one year of clinical RN experience in a hospital, SNF, Home Health, or acute care setting.
• Previous utilization management/utilization review experience in a health plan or acute care setting.
• Basic knowledge of medical necessity criteria such as 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 coordinate medical services and benefit determinations using established nursing skills.
• Communicate with providers, members, or other parties to facilitate care.
• Make determinations based on information from attending physician and other care providers using established criteria.
• Deliver coordinated care for Humana members and support documentation.

Skills

Compact RN license

RN clinical experience (hospital/SNF/H

Utilization management experience

Medical necessity criteria knowledge

Remote/metrics-focused experience

MDS Coordinator/Discharge planning

Medicare Home Health RN experience

Call center/triage experience

Education

BSN or bachelor's degree in related field

Tools

Milliman Care Guidelines

InterQual

Care Provider Background Screening Clearinghouse

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and support coordination, documentation and benefit determinations for post-acute care services (SNF, Home Health, DME). You will report to the Manager of Utilization Management and work within the One Home/Home Solutions team.

This remote role requires compact RN license in your state, hospital/SNF/Home Health RN experience, and knowledge of criteria such as Milliman Care Guidelines or InterQual.