Remote Utilization Management RN – Care Coordination

Humana; Alabama; 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 (SNF, Home Health, DME). The role reports to the Manager of Utilization Management and is part of the One Home/Home Solutions Utilization Management team.

You will apply clinical nursing expertise to support documentation, communication, and decision-making for member care.

Qualifications

• Must hold Compact RN license in state of residence.
• 1+ year nursing experience in hospital, SNF, home health, or acute care.
• Experience in utilization management / utilization review.
• Familiar with Milliman Care Guidelines or Interqual.
• Experience in a fully remote, metrics-focused role.
• Experience as MDS Coordinator or discharge planner.
• Experience as RN for Medicare/Medicaid Home Health.
• Medicare/Medicaid experience within health plan.
• Call center or triage experience.
• Bachelor's degree in nursing or related field (BSN).

Responsibilities

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

Skills

Utilization management

RN license (Compact)

Clinical nursing experience

MDS coordination / discharge planning

Medicare/Medicaid experience

Call center / triage experience

Remote/work metrics-driven role

Milliman Care Guidelines / Interqual

Post-acute care nursing

Education

BSN or Bachelor's degree in Nursing

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations for post-acute care (SNF, Home Health, DME). The role reports to the Manager of Utilization Management and is part of the One Home/Home Solutions Utilization Management team.

You will apply clinical nursing expertise to support documentation, communication, and decision-making for member care.