Humana is looking for a Utilization Management Registered Nurse to leverage clinical nursing skills in coordinating, documenting, and communicating medical services and benefit determinations. In this role, you will apply your clinical knowledge, communication skills, and critical thinking to interpret criteria and procedures, facilitating the best care for our members.
What You'll Do
- Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.
- Use clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures.
- Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
- Understand department, segment, and organizational strategy and operating objectives.
- Make decisions regarding own work methods, occasionally in ambiguous situations, requiring minimal direction.
- Follow established guidelines and procedures.
What We're Looking For
- Active enhanced Registered Nurse (eNLC) license (RN) with no disciplinary action.
- Ability to obtain multiple state registered nurse licenses.
- Minimum of three (3) years of Medical Surgery, Heart, Lung, maternity/obstetrics, or Critical Care Nursing experience.
- Prior clinical experience preferably in an acute care, skilled, or rehabilitation clinical setting.
- Intermediate to advanced knowledge of Microsoft Word, Outlook, and Excel, systems and platforms.
- Ability to work independently under general instructions and with a team.
Nice to Have
- Bachelor's degree.
- Previous experience in prior authorization, claims, and/or utilization management in healthcare, health insurance, evaluating medical necessity and appropriateness of care.
- Health Plan experience.
- Previous Medicare/Medicaid Experience.
- Bilingual.
Technical Stack
- Microsoft Word, Outlook, Excel
Benefits & Compensation
- Compensation: $71,100 - $97,800 per year.
- Medical, dental and vision benefits.
- 401(k) retirement savings plan.
- Paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave.
- Short-term and long-term disability.
- Life insurance.
Work Mode
This is a remote position. Candidates must reside in a state that participates in the enhanced nurse licensure compact (eNLC).
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.
