Remote Utilization Management RN – Care Coordination

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

Benefits offered by this job

Bonus incentive plan

Job summary

Humana seeks an experienced Utilization Management RN to interpret and coordinate medical services and benefit determinations remotely. You will work with the One Home/Home Solutions UM team, support post-acute care services, and communicate with providers and members to ensure appropriate care levels.

This role requires RN licensure in home state, 1+ year clinical experience, and knowledge of medical necessity criteria.

Qualifications

• Must hold Compact RN license in your state of residence.
• Greater than one year of clinical RN experience in hospital, SNF, home health, or acute care.
• Experience in utilization management / utilization review for a health plan or acute care setting.
• Knowledge of medical necessity criteria (Milliman Care Guidelines or Interqual).
• Experience in a remote, metrics-focused role.
• Experience as an MDS Coordinator or discharge planner in an acute care setting.
• RN experience 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

• Coordinate, document, and communicate medical services and benefit determinations.
• Interpret information from attending physicians and care providers using established criteria.
• Communicate with providers, members, or other parties to facilitate care and treatment.
• Contribute to delivering coordinated care for members.

Skills

Compact RN license

Utilization management experience

Remote/work-from-home experience

MDS coordinator / discharge planning

Home health RN experience

Payer experience (Medicare/Medicaid)

Call center / triage experience

Medical necessity criteria knowledge (

Education

BSN or Bachelor's degree

Job description

Humana seeks an experienced Utilization Management RN to interpret and coordinate medical services and benefit determinations remotely. You will work with the One Home/Home Solutions UM team, support post-acute care services, and communicate with providers and members to ensure appropriate care levels.

This role requires RN licensure in home state, 1+ year clinical experience, and knowledge of medical necessity criteria.