Remote Utilization Management RN

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

Job summary

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

You will apply clinical nursing skills, use criteria to determine care needs, and communicate with providers and members to ensure appropriate care.

Qualifications

• Must hold Compact Registered Nurse (RN) license in your state of residence.
• Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
• Must be passionate about contributing to an organization focused on improving consumer experiences.
• Previous experience in utilization management/utilization review for 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

• Use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
• Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
• Complete request determinations within established processing time frames.
• You will communicate with providers, members, or other parties to facilitate care and treatment.
• You will help deliver coordinated care for our members
• You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.

Skills

RN license

Clinical nursing

Provider communication

Remote work

Care coordination

Education

BSN or bachelor's degree

Job description

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

You will apply clinical nursing skills, use criteria to determine care needs, and communicate with providers and members to ensure appropriate care.