Utilization Management Registered Nurse

Become a part of our caring community and help us put health first

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.

• Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
• Medical necessity reviews for Medicaid claims and Provider disputes.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

• Active unrestricted Compact Registered Nurse, (eNLC) license (RN) with no disciplinary action in the state that you reside, with the ability to obtain multiple state registered nurse license
• At least three (3) years of clinical nursing experience, ideally within acute care, skilled nursing, or rehabilitation settings. This should include experience in areas such as medical-surgical, cardiology, pulmonology, maternity/obstetrics, or critical care nursing.
• Intermediate to advanced knowledge of Microsoft Word, Outlook and Excel, systems and platforms
• Ability to work independently under general instructions and with a team

• Bachelor's degree
• Previous experience in prior authorization, claims, provider disputes and/or utilization management in healthcare, health insurance, evaluating medical necessity and appropriateness of care
• Health Plan/MCO experience
• Previous Medicare/Medicaid Experience a plus

Workstyle:
Remote work at home

Location:

Must reside in a state that participates in the enhanced nurse licensure, (eNLC)

Schedule:

Monday through Friday 8:00 AM to 5:00 PM in most time zones, with ability to work over‑time, weekends as needed to support business needs.

Training:
The training program will span approximately four weeks, with sessions scheduled from 8:00 AM to 5:00 PM Eastern Time. Additional virtual training opportunities will also be provided.

Travel:
Less than 5%

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is required.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

SSN Alert:
Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from  with instructions on how to add the information into your official application on Humana’s secure website.

Interview Format:
As part of our hiring process for this opportunity, we will be using an interviewing technology called Hire Vue to enhance our hiring and decision‑making ability. Hire Vue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

Travel:
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly

Hours:

40

The compensation range below reflects a good faith…