Utilization Management RN

Join Humana's One Home/Home Solutions Utilization Management team, which manages post-acute care services including Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.

Using clinical nursing skills, you will interpret and support the coordination, documentation, and communication of medical services and benefit administration determinations. Apply established medical necessity criteria to information provided by attending physicians and other care providers to render determinations within required processing time frames (approximately 10 reviews per day). Communicate with providers, members, and other parties to facilitate coordinated care and treatment.

Required: Compact RN license in state of residence, and more than one year of clinical RN experience in a hospital, SNF, Home Health, or acute care setting.

Preferred: Prior UM/UR experience for a health plan or acute care setting; working knowledge of MCG or InterQual; experience in a fully remote metrics-focused role; MDS Coordinator or discharge planner background; Medicare-Certified Home Health RN experience; Medicare/Medicaid or health plan experience; call center or triage experience; BSN.

Fully remote with occasional travel to Humana offices for training or meetings. Salary $71,100–$97,800 plus bonus eligibility.