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.

Role Overview:

• 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

Use your skills to make an impact

Required Qualifications

• 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

Preferred Qualifications

• 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

Additional Information

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%

WAH Internet Statement

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• 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 [email protected] 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 HireVue to enhance our hiring and decision-making ability. HireVue 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

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$71,100 - $97,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

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. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.