Remote Utilization Management RN – Care Coordination

Humana; Idaho Falls (ID); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Competitive benefits package

Job summary

Humana is seeking an Utilization Management Registered Nurse to interpret and support coordination, documentation and communication of medical services and benefit determinations. You will determine based on criteria, communicate with providers, and help deliver coordinated care for members in a remote/post-acute care setting.

The role requires an active RN license in your state, 1+ year RN experience, and background in utilization management and Medicare/Medicaid.

Qualifications

• Active Compact RN license in your state of residence.
• Greater than 1 year of RN clinical experience in hospital, SNF, Home Health, or acute care setting.
• 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

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

Skills

RN license

Clinical nursing experience

Utilization management

Medical necessity criteria

Remote work experience

MDS Coordinator

Home Health RN

Medicare/Medicaid experience

Call center/triage

BSN degree

Education

BSN or Bachelor's degree in a related field

Job description

Humana is seeking an Utilization Management Registered Nurse to interpret and support coordination, documentation and communication of medical services and benefit determinations. You will determine based on criteria, communicate with providers, and help deliver coordinated care for members in a remote/post-acute care setting.

The role requires an active RN license in your state, 1+ year RN experience, and background in utilization management and Medicare/Medicaid.