Remote Utilization Management RN (Medicare/Medicaid)

Humana; Philadelphia (Philadelphia County); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Medical, dental and vision benefits

401(k) retirement savings plan

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and support coordination of medical services and benefit determinations for post-acute care. You will collaborate with physicians, providers and members to facilitate care and ensure appropriate settings.

The role requires an active RN license, 1+ year clinical experience, and utilization management exposure, with preference for MDS coordination or discharge planning in acute care.

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
• 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 information provided by attending physicians and other care providers using established medical criteria.
• 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

remote/work-from-home

MDS coordinator

discharge planner

Medicare/Medicaid experience

call center/triage

Milliman Care Guidelines/Interqual

BSN or bachelor's degree

Education

BSN or Bachelor's degree

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and support coordination of medical services and benefit determinations for post-acute care. You will collaborate with physicians, providers and members to facilitate care and ensure appropriate settings.

The role requires an active RN license, 1+ year clinical experience, and utilization management exposure, with preference for MDS coordination or discharge planning in acute care.