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The Utilization Management Nurse uses clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations.
The Utilization Management Nurse uses clinical knowledge to interpret criteria and procedures to provide the best treatment, care, or services for members. You will coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. You will understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas. You will report to a Utilization RN Manager.
Use your skills to make an impact
Required Qualifications
- Active and unrestricted Registered Nurse license (RN) in the (appropriate state) with no disciplinary action
- 3+ years of Medical Surgery, Heart, Lung, or Critical Care Nursing experience
- Previous experience in utilization management
- Prior clinical experience preferably in an acute care, skilled, or rehabilitation clinical setting
- Comprehensive knowledge of Microsoft Word, Outlook, and Excel
Preferred Qualifications
- BSN or Bachelor's degree in a related field
- Health Plan experience
- Previous Medicare/Medicaid Experience
- Call center or triage experience
- Bilingual in English and Spanish with the ability to read/write/speak in both languages
Work environment
This is a remote position.
Additional Information
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.
- Satellite, cellular, and microwave connection can be used only if approved by leadership.
- Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
- Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
- 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.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full-time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job-related skills, knowledge, experience, education, certifications, etc.
$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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance, and many other opportunities.
Application Deadline: 05-08-2026
About us
About Conviva Senior Primary Care
Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment, and more. As part of Humana's Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health — addressing the social, emotional, behavioral, and financial needs that can impact our patients' well-being.
About CenterWell, a Humana company
CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive, and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare, and a leading integrated home delivery, specialty, hospice, and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional, and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer 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.
Centerwell, a wholly owned subsidiary of 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 full accessibility rights information and language options https://www.partnersinprimarycare.com/accessibility-resources