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.

• 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.

• 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 knowledge of Microsoft Word, Outlook and Excel, systems and platforms.
• Ability to work independently under general instructions and with a team.

• 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.

• 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, 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%.

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.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and Center Well 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.