Remote Utilization Management RN

Humana; Guin (AL); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) plan

Paid time off

Disability insurance

Life insurance

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations for post-acute care programs (SNF, Home Health, DME). The role involves consulting with physicians, coordinating member care, and maintaining documentation while working remotely with periodic travel to Humana offices as needed.

You must have a Compact RN license, 1+ year of RN experience, and familiarity with medical necessity criteria.

Qualifications

• Must hold Compact RN license in state of residence.
• Over 1 year RN clinical experience in hospital/SNF/home health/acute care.
• Experience in utilization management/review for health plan or acute care.
• Knowledge of medical necessity criteria (Milliman Care Guidelines or Interqual).
• Experience in a fully remote, metrics-focused role.
• Experience as MDS Coordinator or discharge planner in acute care.
• Experience as RN for a Medicare Certified Home Health agency.
• Health Plan or Medicare/Medicaid experience.
• Call center or triage experience.

Responsibilities

• Interpret and support coordination, documentation, and communication of medical services and benefit determinations.
• Make determinations using established medical criteria based on information from physicians and providers.
• Communicate with providers, members, or other parties to facilitate care and treatment.
• Help deliver coordinated care for Humana members.

Skills

RN license

RN experience

Utilization management

Care guidelines

Remote work experience

MDS Coordinator

Medicare Home Health RN

Medicare/Medicaid experience

Call center/triage

BSN degree

Education

BSN or Bachelor's degree

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations for post-acute care programs (SNF, Home Health, DME). The role involves consulting with physicians, coordinating member care, and maintaining documentation while working remotely with periodic travel to Humana offices as needed.

You must have a Compact RN license, 1+ year of RN experience, and familiarity with medical necessity criteria.