Remote Utilization Management RN — Bonus Eligible

Humana; Columbia (SC); 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 coordinate medical services and benefit determinations for post-acute care services, including SNF, Home Health and DME. This remote role reports to the Manager of Utilization Management and supports a remote team focused on outcomes and efficiency.

The ideal candidate holds a compact RN license, has 1+ year RN experience in acute or post-acute settings, and shows experience in utilization management and

Qualifications

• Must hold a Compact RN license in your state of residence.
• More than one year of RN clinical experience in hospital, SNF, Home Health or acute care.
• Experience in utilization management / utilization review for a health plan or acute care setting.
• Basic knowledge of medical necessity criteria (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.
• RN for a Medicare-Certified Home Health agency.
• Health plan or Medicare/Medicaid experience.
• Call center or triage experience.
• BSN or related bachelor's degree.

Responsibilities

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

Skills

RN license (Compact)

RN experience

Utilization mgmt

Medical criteria knowledge

Remote work experience

MDS Coordinator

Home Health RN

Medicare/Medicaid

Call center experience

BSN

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 services, including SNF, Home Health and DME. This remote role reports to the Manager of Utilization Management and supports a remote team focused on outcomes and efficiency.

The ideal candidate holds a compact RN license, has 1+ year RN experience in acute or post-acute settings, and shows experience in utilization management and