Remote Utilization Management RN Care Coordination

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

Benefits offered by this job

Bonus incentive plan

Job summary

Humana seeks a Utilization Management Registered Nurse to interpret and support medical services coordination, documentation, and benefit determinations. You will work remotely, reporting to the Manager of Utilization Management as part of the One Home/Home Solutions team.

Responsibilities include applying medical criteria to make determinations, communicating with providers and members, and delivering coordinated care for our members in post-acute settings such as SNF, Home Health, and DME.

Qualifications

• Must hold Compact Registered Nurse (RN) license in your state of residence.
• Clinical RN with 1+ year experience in hospital, SNF, Home Health, or acute care.
• Experience in utilization management or utilization review.
• Knowledge of medical necessity criteria (Milliman Care Guidelines/Interqual).
• Experience in a fully remote, metrics-driven role.
• Experience as an MDS Coordinator or discharge planner in an acute care setting.
• Medicare/Medicaid experience with health plans is preferred.
• Call center or triage experience is a plus.
• BSN or bachelor’s degree in a related field.

Responsibilities

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

Skills

RN license

Clinical RN experience

Utilization management

InterQual/Milliman knowledge

Remote work experience

MDS Coordinator experience

Medicare/Medicaid experience

Call center experience

BSN

Education

BSN

Job description

Humana seeks a Utilization Management Registered Nurse to interpret and support medical services coordination, documentation, and benefit determinations. You will work remotely, reporting to the Manager of Utilization Management as part of the One Home/Home Solutions team.

Responsibilities include applying medical criteria to make determinations, communicating with providers and members, and delivering coordinated care for our members in post-acute settings such as SNF, Home Health, and DME.