Remote Utilization Management RN

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

Job summary

Humana is seeking a Utilization Management Registered Nurse for a remote role supporting post-acute care services. You will interpret clinical data, coordinate care, and document determinations using established criteria.

This position may require occasional travel to Humana offices for training or meetings. The role emphasizes remote performance metrics, collaboration with providers, and a focus on delivering appropriate care in the right setting for members enrolled in Medicare and Medicaid

Qualifications

• Must hold Compact RN license in state of residence.
• >1 year of RN clinical experience in hospital/SNF/Home Health/acute care.
• Experience in utilization management or utilization review for a health plan or acute care setting.
• Knowledge of medical necessity criteria (Milliman Care Guidelines/InterQual).
• Experience in a fully remote, metrics-focused role.
• Experience as MDS coordinator or discharge planner in acute care.
• RN for a Medicare Certified Home Health agency beneficial.
• 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 care providers.
• Communicate with providers, members and other parties to facilitate care and treatment.
• Help deliver coordinated care for Humana members.

Skills

RN license (compact)

Clinical experience

Utilization management

Medicare/Medicaid experience

Remote work experience

MDS coordinator/discharge planner

Medicare Home Health RN experience

Call center/triage experience

BSN or related degree

Education

BSN or related degree

Job description

Humana is seeking a Utilization Management Registered Nurse for a remote role supporting post-acute care services. You will interpret clinical data, coordinate care, and document determinations using established criteria.

This position may require occasional travel to Humana offices for training or meetings. The role emphasizes remote performance metrics, collaboration with providers, and a focus on delivering appropriate care in the right setting for members enrolled in Medicare and Medicaid