Remote Utilization Management RN – Care Coordination

Humana; South Carolina; Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Remote-friendly/Hybrid/Home-Office

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 work with the One Home/Home Solutions Utilization Management team handling post-acute care services (SNF, Home Health, DME) to ensure appropriate care in the right setting.

Reporting to the Manager of Utilization Management, you will perform determinations using established criteria, communicate with providers

Qualifications

• Must hold Compact Registered Nurse (RN) license in your state of residence.
• Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
• Must be passionate about contributing to an organization focused on improving consumer experiences.
• Previous experience in utilization management/utilization review for a health plan or acute care setting (preferred).
• Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual (preferred).
• Experience working in a fully remote, metrics-focused role (preferred).
• Experience as an MDS Coordinator or discharge planner in an acute care setting (preferred).
• Experience as an RN for a Medicare Certified Home Health agency (preferred).
• Health Plan or Medicare / Medicaid Experience (preferred).
• Call center or triage experience (preferred).
• BSN or bachelor's degree in a related field (preferred).

Responsibilities

• You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
• Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
• You will complete request determinations within established processing time frames.
• You will communicate with providers, members, or other parties to facilitate care and treatment.
• You will help deliver coordinated care for our members
• You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.

Skills

RN license in state

Clinical RN experience

Patient focus

Education

BSN or related bachelor's degree

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 work with the One Home/Home Solutions Utilization Management team handling post-acute care services (SNF, Home Health, DME) to ensure appropriate care in the right setting.

Reporting to the Manager of Utilization Management, you will perform determinations using established criteria, communicate with providers