Remote Utilization Management RN – Care Coordination Expert

Humana; Virginia Beach (VA); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Competitive benefits package

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations for post-acute care settings, including SNF, home health, and DME. You will report to the Manager of Utilization Management and support the One Home/Home Solutions UM team.

The RN applies clinical skills and established criteria to make determinations, communicates with providers and members to facilitate care, and contributes to coordinated care.

Qualifications

• Must hold Compact RN license in your state of residence.
• 1+ year of clinical experience as an RN in hospital, SNF, home health, or acute care.
• Previous 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

• Interpret and support coordination, documentation and communication of medical services and benefit determinations.
• Make determinations based on established medical criteria from attending physicians and other care providers.
• Communicate with providers, members, or other parties to facilitate care and treatment.
• Help deliver coordinated care for our members.

Skills

Clinical nursing

RN license

Remote work experience

Communication with providers

Care coordination

MDS coordination / discharge planning

Medicare/Medicaid knowledge

Call center / triage

Education

BSN or bachelor’s degree

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations for post-acute care settings, including SNF, home health, and DME. You will report to the Manager of Utilization Management and support the One Home/Home Solutions UM team.

The RN applies clinical skills and established criteria to make determinations, communicates with providers and members to facilitate care, and contributes to coordinated care.