Remote Utilization Management RN – Care Coordinator

Humana Inc; Atlanta (GA); Remote; USD 71,000 - 98,000; Full time

Job summary

Humana Inc. is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations, reporting to the Manager of Utilization Management.

The role supports post-acute care services including SNF, Home Health and DME, with a focus on delivering appropriate care in the right setting. The RN uses established criteria to make determinations, communicates with providers and members, and works in a remote, metrics-driven environment with occasional

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
• 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 the coordination, documentation and communication of medical services and benefit administration determinations.
• Make determinations based on established medical criteria using 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

Job description

Humana Inc. is seeking a Utilization Management Registered Nurse to interpret and coordinate medical services and benefit determinations, reporting to the Manager of Utilization Management.

The role supports post-acute care services including SNF, Home Health and DME, with a focus on delivering appropriate care in the right setting. The RN uses established criteria to make determinations, communicates with providers and members, and works in a remote, metrics-driven environment with occasional