Remote Utilization Management RN - Care Coordination

Humana Inc; Austin (TX); Remote; USD 71,000 - 98,000; Full time

Job summary

Humana Inc. is seeking a remote Utilization Management Registered Nurse to interpret clinical data and coordinate medical service determinations for home solutions and post‑acute care.

You will review, document, and communicate with providers to ensure appropriate care levels and timely processing, reporting to the Manager of Utilization Management. The role emphasizes evidence-based criteria, collaboration with care teams, and adherence to HIPAA/privacy standards while supporting member

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.

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, make determinations based on information provided by the attending physician and other care providers
• Complete request determinations within established processing time frames.
• Communicate with providers, members, or other parties to facilitate care and treatment.
• Help deliver coordinated care for our members
• Understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.

Skills

Clinical Nursing

Patient care coordination

Communication skills

Education

RN license (Compact)

BSN or Bachelor's degree

Tools

Milliman Care Guidelines

Interqual

Job description

Humana Inc. is seeking a remote Utilization Management Registered Nurse to interpret clinical data and coordinate medical service determinations for home solutions and post‑acute care.

You will review, document, and communicate with providers to ensure appropriate care levels and timely processing, reporting to the Manager of Utilization Management. The role emphasizes evidence-based criteria, collaboration with care teams, and adherence to HIPAA/privacy standards while supporting member