[Remote] Utilization Management Nurse at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health InsuranceIndustries

Requirements

Candidates must possess a Licensed Registered Nurse (RN) license in the appropriate state with no disciplinary actions, and have at least 3 years of prior clinical experience as a nurse in an acute care setting. Comprehensive knowledge of Microsoft Word, Outlook, and Excel is required, along with excellent verbal and written communication skills. The ability to work independently under general instructions and as part of a team is essential. Preferred qualifications include a BSN or Bachelor's degree in a related field, health plan experience, experience in utilization management, and previous Medicare or Milliman MCG experience.

Responsibilities

The Utilization Management Nurse will utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. This role involves interpreting criteria, policies, and procedures to ensure the most appropriate treatment, care, or services for members. Responsibilities include coordinating and communicating with providers, members, and other parties to facilitate optimal care, making decisions regarding work methods, and following established guidelines and procedures.

Skills

Clinical Nursing Skills

Medical Services Coordination

Benefit Administration

Critical Thinking

Microsoft Word

Microsoft Outlook

Microsoft Excel

Verbal Communication

Written Communication

Independent Work

Team Collaboration

Acute Care

Utilization Management

Medicare

Milliman MCG

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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