Utilization Management Nurse

Become a part of our caring community   The Part C Grievance & Appeals (G&A) Nurse (Utilization Management Nurse 2) utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. Your work assignments will be varied and frequently require interpretation and independent determination of the appropriate courses of action. Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. You will review the medical documentation, researching claims, benefits, as well as prior determinations pertinent to the appeal and provides a written summary of findings using a template for each case. You will work and collaborate with Humana CIT teams, Vendors, G&A specialists, and Humana Medical Directors on submitted G&A cases. You will participate in initiatives which result in improved member outcomes, operational efficiencies, and process improvement opportunities. Case preparation of Medicare and/or Duals line of business involving expedited, pre-service and post service appeals Apply and implement Medicare, Medicaid, MCG, claims policy and evidence of coverage guidelines for reviews Perform outreach to providers and/or members Utilize multiple systems such as MHK, CGX, MRM, SRO Use your skills to make an impact   Required Qualifications Associate's Degree Licensed Registered Nurse (RN) with compact license in the (appropriate state) with no disciplinary action 3 or more years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting or broad clinical nursing experience Comprehensive knowledge of Microsoft Word, Outlook and Excel Ability to work independently under general instructions and with a team Preferred Qualifications BSN or Bachelor's degree in a related field Appeal Review Experience Knowledge of MHK Medicare/Medicaid Experience Experience in utilization management Claims experience Leadership experience Additional Information The Part C Grievance & Appeals (G&A) Nurse will be a Weekend Team Lead to support the Appeals team, with a strong focus on inventory management. This is a regular, full-time position covering Saturdays and Sundays weekly, with flexible weekday scheduling options. This role includes a required holiday rotation. This is a remote position. This role is responsible for overseeing weekend workflow, monitoring appeal inventory, prioritizing case assignments, and helping ensure timely and accurate processing in alignment with operational and compliance expectations. The Weekend Team Lead will serve as a resource for associates, provide real-time guidance, identify inventory risks and workload gaps, and escalate issues as needed. This position requires strong organizational skills, attention to detail, and the ability to balance production oversight with team support in a fast-paced environment. Work at Home Requirements: 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 suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.   Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.   Florida Background Screening Requirements: Notice for candidates applying to this position from a Florida work location, including Florida home-based work location. This