Remote Utilization Management RN – Care Coordination Expert

Humana Inc; New Jersey; On-site; USD 71,000 - 98,000; Full time

Job summary

Humana Inc. is seeking a Utilization Management Registered Nurse to interpret and support the coordination, documentation and communication of medical services and benefit determinations while contributing to post-acute care management.

You will work within the One Home/Home Solutions Utilization Management team in a fully remote, metrics-driven environment, handling SNF, Home Health and DME coordination with a focus on patient outcomes and timely determinations.

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.
• Preferred knowledge of utilization management criteria such as Milliman Care Guidelines or InterQual.
• Experience in a fully remote, metrics-focused role is preferred.
• BSN or bachelor’s degree in a related field is preferred.

Responsibilities

• You will use clinical nursing skills to interpret and support coordination, documentation and communication of medical services and benefit 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.

Skills

RN license

Clinical RN experience

Utilization management knowledge

Medical necessity criteria

MDS Coordinator experience

Discharge planning experience

Medicare/Medicaid experience

Education

BSN or related bachelor’s degree

Job description

Humana Inc. is seeking a Utilization Management Registered Nurse to interpret and support the coordination, documentation and communication of medical services and benefit determinations while contributing to post-acute care management.

You will work within the One Home/Home Solutions Utilization Management team in a fully remote, metrics-driven environment, handling SNF, Home Health and DME coordination with a focus on patient outcomes and timely determinations.