[Remote] RN, Utilization Management Nurse at Humana

Michigan, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Active, unrestricted Registered Nurse (RN) license in Michigan, Ohio, Illinois, or Indiana
One (1) year of previous experience in utilization management/LTSS service authorization
Two (2) years prior clinical experience, preferably in acute care, skilled or rehabilitation clinical setting, or Medicaid Managed Care Organization
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Ability to work independently under general instructions and with a team
Must reside in the state of Michigan, Ohio, Illinois or Indiana
Must be able to work Eastern Standard Time, Monday – Friday; 8:00am – 5:00pm in Eastern Standard Time (EST)

Responsibilities

Interpreting criteria, policies, and procedures related to Long Term Services and Support authorizations to provide the best and most appropriate treatment, care, or services for members
Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment
Understand department and organizational strategy and operating objectives, including their linkages to related areas
Follow established guidelines/procedures
Make decisions regarding own work methods, occasionally in ambiguous situations, requires minimal direction and receives guidance where needed
Use clinical knowledge, communication skills, and independent critical thinking skills

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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