Humana
Join to apply for the
Utilization Management Registered Nurse
role at
Humana .
This range is provided by Humana. Your actual pay will be based on your skills and experience – talk with your recruiter to learn more.
Base pay range $71,100.00/yr - $97,800.00/yr
Role Overview The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. Assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
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 personal work methods, occasionally in ambiguous situations, and requires minimal direction but receives guidance where needed.
Responsible for medical necessity reviews for Medicaid claims and provider disputes.
Passionate about contributing to an organization focused on continuously improving consumer experiences.
Required Qualifications
Active unrestricted Compact Registered Nurse (RN) license in the state of residence, with ability to obtain multiple state RN licenses, and no disciplinary action.
At least three (3) years of clinical nursing experience, ideally within acute care, skilled nursing, or rehabilitation settings (medical‑surgical, cardiology, pulmonology, maternity/obstetrics, or critical care).
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 or health insurance.
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 overtime and weekends as needed.
Training:
Training program spans approximately four weeks, scheduled 8:00 AM–5:00 PM Eastern Time; additional virtual training opportunities provided.
Travel:
Less than 5%.
Internet Requirement (WAH):
Minimum download 25 Mbps and upload 10 Mbps, wireless/wired/DSL connection; satellite/cellular/microwave permitted only upon approval. Humana will provide telephone equipment. Work in a dedicated space free of interruptions to protect member PHI/HIPAA.
SSN Alert Humana values personal identity protection. Applicants may be asked to provide Social Security Number if not already on file. An email will be sent from Humana@myworkday.com with instructions on how to add the information to your official application on Humana’s secure website.
Interview Format We use HireVue technology for interviews to quickly connect and gain valuable information about relevant skills and experience.
Travel Note:
Although the position is remote, occasional travel to Humana’s offices for training or meetings may be required.
Description of Benefits Humana offers competitive benefits supporting whole‑person well‑being: medical, dental, vision, 401(k), paid time off, holiday, volunteer time off, paid parental and caregiver leave, disability, life insurance, and more.
About Us Humana Inc. (NYSE: HUM) is committed to putting health first for teammates, customers, and the company. Through insurance services and CenterWell healthcare services, we help millions to achieve best health.
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. Humana also takes affirmative action in compliance with Section 503 of the Rehabilitation Act and VEVRAA to employ and advance individuals with disability or protected veteran status, basing all employment decisions solely on valid job requirements.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
Industries Insurance
#J-18808-Ljbffr
Utilization Management Registered Nurse
role at
Humana .
This range is provided by Humana. Your actual pay will be based on your skills and experience – talk with your recruiter to learn more.
Base pay range $71,100.00/yr - $97,800.00/yr
Role Overview The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. Assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
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 personal work methods, occasionally in ambiguous situations, and requires minimal direction but receives guidance where needed.
Responsible for medical necessity reviews for Medicaid claims and provider disputes.
Passionate about contributing to an organization focused on continuously improving consumer experiences.
Required Qualifications
Active unrestricted Compact Registered Nurse (RN) license in the state of residence, with ability to obtain multiple state RN licenses, and no disciplinary action.
At least three (3) years of clinical nursing experience, ideally within acute care, skilled nursing, or rehabilitation settings (medical‑surgical, cardiology, pulmonology, maternity/obstetrics, or critical care).
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 or health insurance.
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 overtime and weekends as needed.
Training:
Training program spans approximately four weeks, scheduled 8:00 AM–5:00 PM Eastern Time; additional virtual training opportunities provided.
Travel:
Less than 5%.
Internet Requirement (WAH):
Minimum download 25 Mbps and upload 10 Mbps, wireless/wired/DSL connection; satellite/cellular/microwave permitted only upon approval. Humana will provide telephone equipment. Work in a dedicated space free of interruptions to protect member PHI/HIPAA.
SSN Alert Humana values personal identity protection. Applicants may be asked to provide Social Security Number if not already on file. An email will be sent from Humana@myworkday.com with instructions on how to add the information to your official application on Humana’s secure website.
Interview Format We use HireVue technology for interviews to quickly connect and gain valuable information about relevant skills and experience.
Travel Note:
Although the position is remote, occasional travel to Humana’s offices for training or meetings may be required.
Description of Benefits Humana offers competitive benefits supporting whole‑person well‑being: medical, dental, vision, 401(k), paid time off, holiday, volunteer time off, paid parental and caregiver leave, disability, life insurance, and more.
About Us Humana Inc. (NYSE: HUM) is committed to putting health first for teammates, customers, and the company. Through insurance services and CenterWell healthcare services, we help millions to achieve best health.
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. Humana also takes affirmative action in compliance with Section 503 of the Rehabilitation Act and VEVRAA to employ and advance individuals with disability or protected veteran status, basing all employment decisions solely on valid job requirements.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
Industries Insurance
#J-18808-Ljbffr