RN Utilization Management

Florida, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Plan, HealthcareIndustries

Requirements

Candidates must possess an active RN license in Florida with no disciplinary actions, along with one or more years of experience in Utilization Management and at least two years of clinical experience in acute care, skilled, or rehabilitation settings focusing on adults. Proficiency in Microsoft Word, Outlook, and Excel is required. A BSN or Bachelor's degree in a related field, Medicare/Medicaid health plan experience, MCG experience, and bilingual skills are preferred. The ability to work independently under general instructions and as part of a team is also necessary.

Responsibilities

The Utilization Management Nurse will leverage clinical nursing skills to coordinate, document, and communicate medical services and benefit administration determinations. This role involves interpreting criteria, policies, and procedures to ensure members receive the most appropriate treatment and care. Responsibilities include coordinating and communicating with providers, members, and other parties to facilitate optimal care and making decisions regarding work methods with minimal direction.

Skills

Utilization Management

Registered Nurse (RN)

Clinical Nursing

Medical Services

Benefit Administration

Microsoft Word

Microsoft Outlook

Microsoft Excel

Medicare

Medicaid

MCG

Case Management

Bilingual

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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