Utilization Management Nurse

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $71.1k - $97.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Support coordination, documentation and communication of medical services and/or benefit administration determinations • Assist in preparing Part C Medicare and/or Duals grievance and appeal cases for review by Humana G&A Medicare Medical Directors • Review medical documentation, research claims, benefits and prior determinations pertinent to appeals • Provide a written summary of findings using a case template • Collaborate with Humana CIT teams, vendors, G&A specialists and Humana Medical Directors • Prepare expedited, pre-service and post-service Medicare and/or Duals appeals • Apply Medicare, Medicaid, MCG, claims policy and evidence of coverage guidelines • Conduct outreach to providers and/or members • Use MHK, CGX, MRM and SRO systems • Participate in initiatives improving member outcomes, operational efficiency and processes • Oversee weekend workflow and monitor appeal inventory • Prioritize case assignments and support timely, accurate processing aligned with operational and compliance expectations • Serve as a resource for associates, provide real-time guidance, identify inventory risks and workload gaps, and escalate issues as needed

🎯 Requirements

• Associate's Degree • Licensed Registered Nurse (RN) with compact license in the appropriate state and 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 • Required holiday rotation • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information • Minimum internet download speed of 25 Mbps and upload speed of 10 Mbps • BSN or Bachelor's degree in a related field (preferred) • Appeal Review Experience (preferred) • Knowledge of MHK (preferred) • Medicare/Medicaid Experience (preferred) • Experience in utilization management (preferred) • Claims experience (preferred) • Leadership experience (preferred)

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Personal wellness and smart healthcare decision support • Remote work arrangement • Flexible weekday scheduling options • Training and meetings travel support as applicable