[Remote] Utilization Management Nurse at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Licensed Registered Nurse (RN) Compact license, with no disciplinary action
3 years of prior clinical experience as an RN
Proven ability to work independently (i.e., taking initiative to utilize resources to enable decision making)
Computer proficiency: comfortable working with and on computers as well as within multiple systems simultaneously, including efficient use of Microsoft products (i.e., Word, Excel, etc.)
Strong verbal and written communication skills
Excellent organizational and time management skills
Work-at-home setup: self-provided internet with minimum download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable or DSL suggested; satellite, cellular, or microwave only if approved); dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information
Ability to work Monday-Friday 7am-5pm CST (8-hour shift within this timeframe), with occasional weekend work; must work in Central Standard Time Zone

Responsibilities

Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations
Interpret criteria, policies, and procedures using clinical knowledge, communication skills, and independent critical thinking 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
Make decisions regarding own work methods, occasionally in ambiguous situations, with minimal direction and guidance where needed
Follow established guidelines/procedures
Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas

Skills

Key technologies and capabilities for this role

Registered Nurse (RN)Utilization ManagementClinical NursingMicrosoft WordMicrosoft ExcelMedicare RegulationsMedicaid Regulations

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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