RN, Utilization Management (Clinical Claims Review)

Become a part of our caring community   The Utilization Management Nurse 2 uses clinical nursing skills to support the coordination, documentation and communication of medical services 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. Employees use these skills towards interpreting criteria and procedures. The goal is to provide the best treatment, care, or services for members. Coordinate and communicate with providers, members, or other parties to facilitate care and treatment. Understand department, segment, and organizational strategy and operating goals, including their linkages to related areas Follow established guidelines/procedures. Must be passionate about contributing to an organization focused on improving consumer experiences Use your skills to make an impact   Required Qualifications Licensed Registered Nurse (RN) in an Enhanced Nurse Licensure Compact (eNLC) state, with no disciplinary actions. Ability to obtain and maintain multiple state Registered Nurse (RN) licenses. 3+ years of experience in prior authorization, claims review, utilization management, or other healthcare/health insurance environments involving assessment of medical necessity, appropriateness of care, and clinical decision-making. 3+ years of nursing experience in one or more of the following areas: Medical-Surgical, Cardiac, Pulmonary, Maternity/Obstetrics, or Critical Care . Prior clinical experience in acute care, skilled nursing, rehabilitation, or a similar healthcare setting. Intermediate to advanced proficiency in Microsoft Office applications, including Word, Outlook, and Excel , with the ability to navigate multiple systems and platforms.

Bachelor's degree in Nursing (BSN) or a related healthcare field. Previous experience working for a health plan, managed care organization (MCO), or health insurance provider. Experience supporting Medicare or Medicaid populations. Bilingual proficiency in Spanish and English Additional Information Schedule: Monday through Friday, 8:00 AM – 5:00 PM with flexibility to work overtime as needed. Work Location: US Nationwide Work Style: Remote Travel Requirements: None 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 position is subject to Florida Level 2 background screening through the Care Provider Background Screening Clearinghouse. For information about the screening process and requirements, visit: https://info.flclearinghouse.com. 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