Remote Utilization Management RN

Humana; Idaho Falls (ID); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and support the coordination, documentation and communication of medical services and benefit determinations. You will work with the One Home/Home Solutions Utilization Management team, handling post-acute care services including SNF, Home Health and DME.

The role emphasizes remote work with travel for training/meetings, a strong focus on patient care, and adherence to healthcare criteria like Milliman/InterQual.

Qualifications

• Must hold Compact RN license in your state of residence.
• Greater than one year of clinical RN experience in hospital, SNF, home health or acute care.
• Must be passionate about contributing to an organization focused on improving consumer experiences.
• Preferred: utilization management/ utilization review experience for a health plan or acute care setting.
• Knowledge of Milliman Care Guidelines or InterQual.
• Experience 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 administration determinations.
• Make determinations using established medical criteria based on information from physicians and care providers.
• Complete request determinations within established processing time frames.
• Communicate with providers, members or other parties to facilitate care and treatment.
• Help deliver coordinated care for our members.
• Understand department, segment, and organizational strategy and operating goals and their linkages to related areas.

Education

Compact RN license

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and support the coordination, documentation and communication of medical services and benefit determinations. You will work with the One Home/Home Solutions Utilization Management team, handling post-acute care services including SNF, Home Health and DME.

The role emphasizes remote work with travel for training/meetings, a strong focus on patient care, and adherence to healthcare criteria like Milliman/InterQual.