Utilization Management RN; Discharge & Auth Weekends

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The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations for Humana’s Kentucky Medicaid Plan. The role is responsible for performing medical necessity reviews, including initial and concurrent authorization decisions, using established clinical criteria and independent clinical judgment. The Utilization Management Nurse 2 also facilitates comprehensive, proactive, and barrier-focused discharge planning to home or a lower level of care, interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.

The position coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment, maintains compliance with state regulations and organizational standards, and performs initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions. Engagement with providers via telephonic, virtual, and onsite collaboration is required, following established guidelines and procedures.

• Licensed Registered Nurse (RN) in the state of Kentucky, in good standing with no disciplinary action.
• 2+ years of progressive clinical experience in an acute care, skilled nursing, or rehabilitation setting (preferred).
• 1+ year of utilization management experience.
• Experience performing initial and concurrent reviews for medical service requests, with the ability to interpret clinical criteria and apply judgment to support appropriate use and benefit administration.
• Experience engaging with providers and care teams through telephonic, virtual, or onsite interactions to facilitate authorizations and support member-centered discharge planning.
• Strong proficiency in Microsoft Office Suite, including Word, Excel, and PowerPoint.

• Bachelor's degree in nursing.
• MCG experience.
• Experience in discharge planning, transitions of care, and familiarity with community-based resources and social determinants of health.
• Health plan experience.
• Medicaid experience.
• Bilingual in English and another language (with a Language Proficiency Assessment conducted prior to assignment).

Workstyle:
Remote work at home.

Location:

Must reside in Kentucky or a county that is within contiguous bordering states.

Schedule:

The position will include weekend shifts (Wednesday through Sunday, 8:00AM to 5:00PM Eastern Time). Weekend shifts are eligible for a shift differential. The role follows a 5-day workweek, which includes both Saturday and Sunday. Associates will receive two days off during the week; those days must remain consistent from week to week and cannot vary.

Travel:
Travel to the Louisville office about 3–4 times annually for training or meetings. Work from home requires a self-provided internet connection with a minimum download speed of 25

Mbps and upload speed of 10

Mbps; wireless or wired connection is suggested. Employees must work from a dedicated space that protects member PHI/HIPAA information.

Scheduled Weekly

Hours:

40. Pay Range: $71,100 - $97,800 per year, based on location and experience. The position is eligible for a bonus incentive plan.

Description of Benefits:
Humana provides medical, dental, and vision benefits, a 401(k) retirement savings plan, paid time off (including company and personal holidays), paid parental and caregiver leave, short- and long-term disability, life insurance, and other opportunities supporting whole-person well-being.

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 disabilities or protected veteran status, basing all employment decisions only on valid job requirements.