Remote Utilization Management RN — Care Coordination

Humana; West Virginia; Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana is seeking an experienced Utilization Management Registered Nurse to interpret and support medical services and benefit determinations. You will report to the Manager of Utilization Management and serve on the One Home/Home Solutions UM team focusing on post-acute care (SNF, Home Health, DME).

The role emphasizes coordinating care, communicating with providers and members, and applying clinical criteria to make timely determinations in a remote-work setting.

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.

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, you will make determinations based on information provided by the attending physician and other care providers.
• Complete request determinations within established processing time frames.
• Communicate with providers, members, or other parties to facilitate care and treatment.
• Help deliver coordinated care for our members
• Understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.

Skills

RN license

Clinical RN experience

Patient-focused care

Job description

Humana is seeking an experienced Utilization Management Registered Nurse to interpret and support medical services and benefit determinations. You will report to the Manager of Utilization Management and serve on the One Home/Home Solutions UM team focusing on post-acute care (SNF, Home Health, DME).

The role emphasizes coordinating care, communicating with providers and members, and applying clinical criteria to make timely determinations in a remote-work setting.