Remote Utilization Management RN for Care Coordination

Humana Inc; Jackson (MS); On-site; USD 71,000 - 98,000; Full time

Job summary

Humana Inc. is seeking a Utilization Management Registered Nurse to interpret and support coordination of medical services and benefit determinations for post-acute care services.

The role reports to the Manager of Utilization Management and participates as a member of the One Home/Home Solutions Utilization Management team. Remote work is allowed with occasional travel for training or meetings.

Qualifications

• Must hold Compact RN license in your state of residence.
• 1+ year clinical RN experience in a hospital, SNF, Home Health, or acute care setting.
• Must be passionate about contributing to an organization focused on improving consumer experiences.
• Experience in utilization management/utilization review for a health plan or acute care setting.
• Knowledge of Milliman Care Guidelines or InterQual.
• Experience in 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 using established medical criteria from 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.

Skills

RN license (Compact)

Clinical RN experience

Patient-focused

Utilization management experience

Remote/work-from-home

MDS coordinator

Discharge planning

Medicare/Medicaid experience

Call center/triage

BSN

Education

BSN or related degree

Job description

Humana Inc. is seeking a Utilization Management Registered Nurse to interpret and support coordination of medical services and benefit determinations for post-acute care services.

The role reports to the Manager of Utilization Management and participates as a member of the One Home/Home Solutions Utilization Management team. Remote work is allowed with occasional travel for training or meetings.