Utilization Management Nurse

Part C Grievance & Appeals 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 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 $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.

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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our