Utilization Management Registered Nurse

Job Title

Utilization Management Registered Nurse

$71,100.00/yr - $97,800.00/yr

• 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.
• Conducts medical necessity reviews for Medicaid claims and provider disputes.

• Utilize clinical nursing skills to support coordination, documentation, and communication of medical services and benefit administration determinations.
• Interpret criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.
• Work independently under general instructions and collaborate with a team.

• Active unrestricted Compact Registered Nurse (RN) license in the state of residence, with the ability to obtain multiple state licenses.
• At least three (3) years of clinical nursing experience, ideally in acute care, skilled nursing, or rehabilitation settings.
• Intermediate to advanced knowledge of Microsoft Word, Outlook, and Excel.

• Bachelor’s degree.
• Experience in prior authorization, claims, provider disputes, or utilization management.
• Health Plan/MCO experience.
• Previous Medicare/Medicaid experience.

Remote work t reside in a state that participates in the enhanced nurse licensure program (eNLC).

Monday through Friday, 8:00 AM – 5:00 PM (most time zones). Availability to work overtime and weekends as needed.

Four‑week training program from 8:00 AM to 5:00 PM Eastern Time, with additional virtual sessions.

Less than 5%.

Humana offers medical, dental & vision benefits; a 401(k) retirement plan; paid time off, company holidays, volunteer time; short‑term & long‑term disability; life insurance.

Humana is an equal‑opportunity employer and does not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status.