Remote Utilization Management RN | Care Coordination

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

Benefits offered by this job

Bonus incentive plan

Job summary

Humana’s Utilization Management team seeks a registered nurse to interpret and coordinate medical services, benefit determinations, and post-acute care support from home. The role emphasizes coordinated care across SNF, Home Health, and DME settings.

You will review information from physicians and care teams, complete determinations within set time frames, and communicate with providers and members to ensure appropriate care in the right setting. Travel may be required.

Qualifications

• Must hold Compact RN license in your state of residence.
• Greater than one year of clinical RN experience.
• Must be passionate about contributing to an organization focused on improving consumer experiences.
• Preferred experience in utilization management/utilization review for a health plan or acute care setting.
• Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
• Experience working 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

• Use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
• Using established medical criteria, make determinations based on information provided by the attending physician and other care providers.
• Complete request determinations within established processing time frames.

Skills

RN license

Clinical experience

Patient care coordination

Remote work experience

Education

BSN or higher

Job description

Humana’s Utilization Management team seeks a registered nurse to interpret and coordinate medical services, benefit determinations, and post-acute care support from home. The role emphasizes coordinated care across SNF, Home Health, and DME settings.

You will review information from physicians and care teams, complete determinations within set time frames, and communicate with providers and members to ensure appropriate care in the right setting. Travel may be required.