Remote Utilization Management RN – Care Coordination

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

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 report to the Manager of Utilization Management and serve on the One Home/Home Solutions Utilization Management team managing post-acute services (SNF, Home Health, DME).

You will use established medical criteria to make determinations and ensure timely processing while collaborating with providers and

Qualifications

• Must hold RN license in your state of residence.
• Greater than one year of clinical RN experience in hospital, SNF, home health, or acute care.
• Passionate about improving consumer experiences.
• Preferred: experience in utilization management or utilization review.
• Knowledge of 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.
• Experience as an RN for a Medicare/Medicaid Home Health agency.
• Health Plan or Medicare/Medicaid experience.
• Call center or triage experience.
• BSN or bachelor's degree in a related field.

Responsibilities

• You will interpret and support coordination, documentation and communication of medical services and benefit determinations.
• You will make determinations based on established medical criteria from physician information.
• You will complete request determinations within established processing time frames.
• You will communicate with providers, members, or other parties to facilitate care and treatment.
• You will help deliver coordinated care for members.
• You will understand department, segment, and organizational strategy and goals.

Skills

RN license

Clinical RN experience

Patient experience

Utilization review

Remote work experience

MDS Coordinator

Discharge planning

Medicare/Medicaid experience

Call center experience

Education

BSN

Tools

Milliman Care Guidelines

Interqual

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 report to the Manager of Utilization Management and serve on the One Home/Home Solutions Utilization Management team managing post-acute services (SNF, Home Health, DME).

You will use established medical criteria to make determinations and ensure timely processing while collaborating with providers and