Remote Utilization Management RN – Care Coordination

Humana; Phoenix (AZ); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana is seeking a 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 join a remote team focused on post-acute care services including SNF, Home Health, and DME.

Responsibilities include applying medical criteria, making determinations, communicating with providers and members, and ensuring appropriate care.

Qualifications

• RN license in resident state.
• >1 year RN clinical experience in hospital/SNF/Home Health/acute care.
• Experience in utilization management/utilization review for health plan or acute care.
• Knowledge of medical necessity criteria (Milliman/InterQual).
• Experience in remote, metrics-focused roles.
• Experience as MDS coordinator or discharge planner in acute care.
• RN for a Medicare-certified Home Health agency.
• Medicare/Medicaid experience.

Responsibilities

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

Skills

RN license

Clinical RN experience

Utilization management

Remote work experience

Medicare/Medicaid knowledge

Call center experience

BSN degree

Milliman Care Guidelines

InterQual criteria

Education

BSN or Bachelor's degree

Tools

Milliman Care Guidelines

InterQual

Job description

Humana is seeking a 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 join a remote team focused on post-acute care services including SNF, Home Health, and DME.

Responsibilities include applying medical criteria, making determinations, communicating with providers and members, and ensuring appropriate care.