Remote Utilization Management RN - Care Coordinator

Humana; Columbus (OH); Remote; USD 71,000 - 98,000; Full time

Job summary

Humana is seeking an Utilization Management Registered Nurse to interpret and support coordination, documentation and communication of medical services and benefit determinations. You will work with providers and members to facilitate care and ensure appropriate care levels across SNF, home health and DME settings.

The role requires compact RN licensure, over one year of clinical RN experience in relevant settings, and knowledge of Milliman/InterQual criteria.

Qualifications

• Must hold Compact RN license in state of residence.
• >1 year clinical RN experience in hospital/SNF/home health/acute care.
• Experience in utilization management or utilization review for health plan or acute care.
• Basic knowledge of medical necessity criteria (Milliman or InterQual).
• Experience in a fully remote, metrics-focused role.
• RN experience in Medicare/Medicaid context preferred.

Responsibilities

• Interpret and support coordination, documentation and communication of medical services and benefit determinations.
• Communicate with providers, members, and other parties to facilitate care and treatment.
• Deliver coordinated care for members and ensure appropriate level of care across settings.

Skills

RN license

Remote work experience

Clinical nursing

Medical necessity criteria

Call center/triage

Education

BSN or related bachelor's

Tools

Milliman Care Guidelines

InterQual

Job description

Humana is seeking an Utilization Management Registered Nurse to interpret and support coordination, documentation and communication of medical services and benefit determinations. You will work with providers and members to facilitate care and ensure appropriate care levels across SNF, home health and DME settings.

The role requires compact RN licensure, over one year of clinical RN experience in relevant settings, and knowledge of Milliman/InterQual criteria.