Utilization Management Nurse – Remote/Work at Home – Florida

May 16, 2020
Any, Florida
Job Type
Job ID or Reference Number
Work Setting
  • Remote
  • Yearly
  • TBD

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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.


The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Required Qualifications

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

+ 3 - 5 years of Medical Surgery, Heart, Lung or Critical Care Nursing experience required, skilled or rehabilitation

+ Previous experience in utilization management using interqual required

+ Comprehensive knowledge of Microsoft Word, Outlook and Excel

+ Ability to work independently under general instructions and with a team

+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Additional Requirement

Work Style/Location: Remote work at Home, must reside within the state of Florida

+ Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work

+ Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required


Hours: MUST be able to work weekends; (4) 10 hour shifts weekly -

+ Shift will include the following days Thursday through Tuesday and will require Saturday and Sunday schedule


Travel: No more than 5%


Preferred Qualifications

+ Education: BSN or Bachelor's degree in a related field

+ Health Plan experience

+ Prior Medical claim interpretation and processing experience

+ MCG Criteria knowledge

+ Certification in Managed Care Nursing

+ Working knowledge of ICD-9, HCPCS, DRG use

+ Previous Medicare/Medicaid Experience a plus

+ Call center or triage experience

+ Bilingual is a plus


Additional Information

Scheduled Weekly Hours: 40


About Us

Mission: At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms -when and where they need it. Our employees are at the heart of making this happen and that's why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.


Equal Opportunity Employer

It is our policy to recruit, hire, train, and promote people without regard to race, color, religion, sex, national origin, age, sexual orientation, gender identity or expression, disability, or veteran status, except where age, sex, or physical status is a bona fide occupational qualification. View the EEO is the Law poster.


If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this online application process and need an alternative method for applying, you may contact mailbox_tas_recruit@humana.com for assistance.


Humana Safety and Security

Humana will never ask, nor require a candidate provide money for work equipment and network access during the application process. If you become aware of any instances where you as a candidate are asked to provide information and do not believe it is a legitimate request from Humana or affiliate, please contact mailbox_tas_recruit@humana.com to validate the request

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