Remote Utilization Management RN – Care Coordination

Humana; New Hampshire; Remote; USD 71,000 - 98,000; Full time

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and support medical services, documentation, and benefit determinations. You will coordinate with physicians and care teams to ensure appropriate care levels and communicate with providers and members to facilitate treatment.

The role emphasizes remote work, prior utilization management experience, and a BSN or higher. Travel to Humana offices may be required occasionally.

Qualifications

• Must hold Compact RN license in state of residence.
• Over one year of RN clinical experience in hospital, SNF, home health or acute care.
• Experience in utilization management or utilization review.
• Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
• Experience in a remote, metrics-focused role; MDS coordinator or discharge planner experience.
• Experience as an RN for a Medicare-certified Home Health agency.
• Health Plan or Medicare/Medicaid experience; call center or triage experience.

Responsibilities

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

Skills

Compact RN license

1+ year RN clinical experience

Utilization management experience

Knowledge of medical necessitycriteria

Remote, metrics-focused role

MDS coordinator or discharge planner

Medicare/Medicaid experience

Call center or triage experience

Education

BSN or bachelor's degree

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and support medical services, documentation, and benefit determinations. You will coordinate with physicians and care teams to ensure appropriate care levels and communicate with providers and members to facilitate treatment.

The role emphasizes remote work, prior utilization management experience, and a BSN or higher. Travel to Humana offices may be required occasionally.