Remote Utilization Management RN — Care Coordination Expert

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

Benefits offered by this job

Bonus incentive plan

Health benefits

401(k) plan

Job summary

Humana is seeking an Utilization Management Registered Nurse to interpret and support the coordination, documentation and communication of medical services and benefit determinations for post-acute care, including SNF, Home Health and DME. You will work remotely reporting to the Manager of Utilization Management.

As an RN, you will use established criteria to make determinations, communicate with providers and members, and help deliver coordinated care.

Qualifications

• Must hold Compact RN license in your state of residence.
• >1 year of clinical RN experience in hospital, SNF, Home Health, or acute care.
• Previous experience in utilization management/review for a health plan or acute care.
• Knowledge of medical necessity criteria such as 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 using established medical criteria based on information from 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

RN license

Clinical nursing

Utilization management

Care criteria knowledge

Remote experience

MDS coordinator

Medicare/Medicaid experience

Call center experience

BSN

Education

BSN or bachelor's degree in a related field

Job description

Humana is seeking an Utilization Management Registered Nurse to interpret and support the coordination, documentation and communication of medical services and benefit determinations for post-acute care, including SNF, Home Health and DME. You will work remotely reporting to the Manager of Utilization Management.

As an RN, you will use established criteria to make determinations, communicate with providers and members, and help deliver coordinated care.