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. Preferred Qualifications 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: 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 is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline 09-09-2026 About us About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. Equal Opportunity Employer 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. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. #J-18808-Ljbffr Humana Inc