Remote Utilization Management RN — Care Coordination

Humana; Rhode Island; 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. You will work with physicians, providers, and members to ensure appropriate care in the right setting, with a focus on remote, metrics-driven performance.

The role emphasizes strong clinical nursing skills, knowledge of criteria, and experience in utilization management across post-acute care services, including SNF, home health, and DME.

Qualifications

• Must hold Compact RN license in your state of residence.
• Over 1 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.
• Basic 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 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

• Interpret, coordinate, document, and communicate medical services and benefit determinations.
• Make determinations using established medical criteria based on information from physicians and care providers.
• Communicate with providers, members, and other parties to facilitate care and treatment.
• Help deliver coordinated care for Humana members.

Skills

RN license (compact)

Clinical RN experience

Utilization management experience

Medical necessity criteria knowledge

Remote metrics-focused role

MDS Coordinator / discharge planning

RN experience in Medicare/Medicaid

Call center or triage experience

BSN or related bachelor's degree

Education

BSN or related bachelor's degree

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations. You will work with physicians, providers, and members to ensure appropriate care in the right setting, with a focus on remote, metrics-driven performance.

The role emphasizes strong clinical nursing skills, knowledge of criteria, and experience in utilization management across post-acute care services, including SNF, home health, and DME.