Remote Utilization Management RN: Care Coordination

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

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations for post-acute care including SNF, Home Health, and DME. You will work remotely, applying Milliman Care Guidelines or InterQual criteria to make determinations based on physician information.

You will communicate with providers and members to facilitate care, deliver coordinated services, and ensure appropriate care in the right setting.

Qualifications

• Must hold Compact RN license in state of residence.
• 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 (Milliman Care Guidelines or Interqual).
• Experience in fully remote, metrics-focused role.
• MDS Coordinator or discharge planner experience 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.

Responsibilities

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

Skills

RN license

RN clinical experience

Utilization management

Medical necessity criteria

Remote work

MDS Coordinator

Medicare Home Health RN

Health plan experience

Call center

Education

BSN or bachelor's degree

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations for post-acute care including SNF, Home Health, and DME. You will work remotely, applying Milliman Care Guidelines or InterQual criteria to make determinations based on physician information.

You will communicate with providers and members to facilitate care, deliver coordinated services, and ensure appropriate care in the right setting.