Utilization Management Nurse

Job Summary The Utilization Management Nurse 2 uses clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. The role requires frequent interpretation and independent determination of appropriate actions based on clinical knowledge, communication, and critical thinking. Responsibilities • Interpret criteria, policies, and procedures to provide the best treatment or services for members.• Coordinate and communicate with providers, members, and other parties to facilitate optimal care.• Make decisions regarding work methods, often in ambiguous situations, with minimal direction.• Follow established guidelines and procedures. Required Qualifications Licensed Registered Nurse (RN) with at least 3 years of prior clinical experience in acute care, skilled nursing, long‑term care, or rehabilitation settings. Licensed Practical Nurse (LPN) with at least 5 years of clinical experience in the same settings. Must reside in the state of Florida and hold an active, discipline‑free license. Ability to work independently under general instructions and as part of a team. Preferred Qualifications BSN or bachelor’s degree in a related field. Prior experience in utilization management/review or prior authorizations. Background in case management for Long‑Term Services and Supports (LTSS) members. Experience with MCG guidelines. Experience evaluating requests for durable medical equipment. Familiarity with health plan operations. Additional Requirements Must work an 8‑hour shift between 8:30AM – 5:30PM local time Monday‑Friday. Remote work may require occasional travel to Humana offices for training or meetings. Home or hybrid employees must provide internet service meeting minimum speed requirements; allowances are provided for certain states. Compensation and Benefits Weekdays: 40 hours per week. Pay Range: $71,100 – $97,800 per year, based on experience, education, and location. Eligible for a bonus incentive plan tied to company or individual performance. Benefits include medical, dental, vision, 401(k), paid time off, disability, life insurance, and more. Equal Opportunity Employer Humana is an equal‑opportunity employer and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. The company also takes affirmative action and bases all employment decisions on valid job requirements. #J-18808-Ljbffr