Humana Inc. is looking for a Utilization Management Registered Nurse to apply clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit determinations. You will use your clinical knowledge and critical thinking to interpret criteria and policies to ensure members receive the most appropriate care.
What You'll Do
- Coordinate and communicate with providers, members, and other parties to facilitate optimal care and treatment.
- Conduct medical necessity reviews for Medicaid claims and provider disputes.
- Make decisions regarding your own work methods, occasionally in ambiguous situations, with minimal direction.
- Follow established guidelines and procedures.
- Understand department and organizational strategy and operating objectives.
What We're Looking For
- Active unrestricted Compact Registered Nurse (eNLC) license (RN) with no disciplinary action in your state of residence, with the ability to obtain multiple state licenses.
- At least three (3) years of clinical nursing experience, ideally within acute care, skilled nursing, or rehabilitation settings.
- Clinical 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 collaborate effectively with a team.
Nice to Have
- Bachelor's degree.
- Previous experience in prior authorization, claims, provider disputes, and/or utilization management in healthcare or health insurance.
- Experience evaluating medical necessity and appropriateness of care.
- Health Plan/MCO experience.
- Previous Medicare/Medicaid Experience.
Technical Stack
- Microsoft Word
- Microsoft Outlook
- Microsoft 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 insurance
- Life insurance
Work Mode
This is a remote position. Candidates must reside in a state that participates in the Enhanced Nurse Licensure Compact (eNLC).
Humana is passionate about contributing to an organization focused on continuously improving consumer experiences and is committed to putting health first for our teammates, our customers, and our company.
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.
