Remote Utilization Management RN Care Coordination Expert

Humana; Provo (UT); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

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 to ensure members receive appropriate care in the right setting.

The role requires a compact RN license in your state, 1+ year RN experience in acute or post-acute care, and knowledge of medical necessity criteria.

Qualifications

• Compact RN license in your state of residence.
• >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 medical necessity criteria (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

• Use clinical nursing skills to interpret and support coordination, documentation and communication of medical services and benefit determinations.
• Make determinations based on established medical criteria from physician information and other care providers.
• Communicate with providers, members, or other parties to facilitate care and treatment.
• Help deliver coordinated care for Humana members.

Skills

Compact RN license

RN experience

Utilization management

Medical necessity criteria

Remote/work-from-home

MDS coordinator/discharge planner

Medicare/Medicaid knowledge

Call center/triage

BSN or related degree

Education

BSN or 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 to ensure members receive appropriate care in the right setting.

The role requires a compact RN license in your state, 1+ year RN experience in acute or post-acute care, and knowledge of medical necessity criteria.