Utilization Management Appeals Nurse

Become a part of our caring community and help us put health first
The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.


Humana is seeking a Part C Grievance & Appeals (G&A) Nurse who will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews the medical documentation, researching claims, benefits, as well as prior determinations pertinent to the appeal and provides a written summary of findings using a template for each case. The associate will be working and collaborating with Humana CIT teams, Vendors, G&A specialists, and Humana Medical Directors on submitted G&A cases.   The G&A Nurse will participate in initiatives which result in improved member outcomes, operational efficiencies, and process improvement opportunities.







Case preparation of Medicare and/or Duals line of business involving expedited, pre-service and post service appeals







Apply and implement Medicare, Medicaid, MCG, claims policy and evidence of coverage guidelines for reviews







Perform outreach to providers and/or members







Utilize multiple systems such as MHK, CGX, MRM, SRO




Use your skills to make an impact


Required Qualifications


Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action

3 or more years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting or broad clinical nursing experience

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Strong organizational and effective time management skills
Ability to work independently under general instructions and with a team




Preferred Qualifications


Bachelor’s degree (BSN)

Appeal Review Experience

Knowledge of MHK

Previous Medicare/Medicaid Experience

Previous experience in utilization management

Previous claims experience




Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: ​


At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
Satellite, cellular and microwave connection can be used only if approved by leadership
Associates 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 associates 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



Additional Information


Hours are Monday-Friday 9am-6pm EST with a weekend rotation (Your 8-hour shift will fall within this timeframe)
Candidate’s must also commit to working on the holidays as needed
This is a remote position, but all candidates must work in the Eastern Standard Time Zone (EST)





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: 11-14-2025

About us
Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.




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.