Remote Utilization Management RN - Medicare/Medicaid Focus

Humana; Santa Fe (NM); Remote; USD 71,000 - 98,000; Full time

Job summary

Humana is seeking a Utilization Management Registered Nurse to interpret and support coordination, documentation, and communication of medical services and benefit determinations. You will rely on established criteria to determine appropriateness based on physician information and other care providers, while communicating with providers, members, and teams to facilitate care.

The role requires an RN license in the state of residence, 1+ year of clinical RN experience in hospital/SNF/home health,

Qualifications

• Must hold Compact Registered Nurse (RN) license in your state of residence.
• Greater than one year of clinical RN experience in hospital, SNF, Home Health, or acute care.
• Experience in utilization management/utilization review for a health plan or acute care.
• Basic knowledge of medical necessity criteria (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

• Interpret and support coordination, documentation and communication of medical services and benefit determinations.
• Make determinations based on information from attending physicians and other care providers using established criteria.
• Communicate with providers, members, or other parties to facilitate care and treatment.
• Help deliver coordinated care for our members.

Skills

Remote work experience

Communication with providers

Call center experience

Healthcare documentation

Education

BSN or Bachelor's degree

Job description

Humana is seeking a Utilization Management Registered Nurse to interpret and support coordination, documentation, and communication of medical services and benefit determinations. You will rely on established criteria to determine appropriateness based on physician information and other care providers, while communicating with providers, members, and teams to facilitate care.

The role requires an RN license in the state of residence, 1+ year of clinical RN experience in hospital/SNF/home health,