Utilization Management Appeals Nurse

Become a Vital Part of Our Healthcare Team! The Utilization Management Appeals Nurse plays a crucial role in coordinating, documenting, and communicating essential medical services and benefit determinations. This position involves diverse responsibilities that require independent decision-making and precise interpretation of actions. As a member of our team, you will prepare cases for evaluation by our Medicare Medical Directors. You will meticulously review medical documentation, investigate claims, and analyze prior determinations related to appeals while providing a comprehensive written summary of your findings. Your collaboration with various teams, including Humana CIT teams, vendors, G&A specialists, and medical directors, will be key to improving member outcomes and operational efficiencies. Prepare cases regarding expedited, pre-service, and post-service appeals for Medicare and Duals lines of business. Implement Medicare, Medicaid, MCG, claims policy, and evidence coverage guidelines during reviews. Conduct outreach to providers and members to gather necessary information. Utilize a range of systems, including MHK, CGX, MRM, and SRO for comprehensive case management. Use Your Expertise to Make a Meaningful Impact! Required Qualifications: Must hold a current Registered Nurse (RN) license in your state with no disciplinary actions. A minimum of 3 years of clinical experience, preferably in acute care, skilled nursing, or rehabilitation settings. Proficient in Microsoft Word, Outlook, and Excel. Possess excellent organizational and time management skills. Ability to work both independently and collaboratively within a team. Preferred Qualifications: Bachelor's degree in Nursing (BSN) is highly desirable. Experience with appeal reviews and processes. Familiarity with MHK is a plus. Experience in Medicare/Medicaid systems is preferred. Background in utilization management is beneficial. Claims experience is an advantage. Work-from-Home Guidelines: Your internet service for remote work must meet the following criteria: A minimum download speed of 25 Mbps and upload speed of 10 Mbps; a wired, DSL, or cable connection is strongly recommended. Satellite, cellular, and microwave connections may only be permitted with management approval. Employees in specific states will receive reimbursements for internet costs. Humana will provide necessary telephone equipment for job performance. Maintain a dedicated, quiet workspace to ensure member privacy and comply with HIPAA regulations. Additional Information: Hours: Monday-Friday, 9 AM - 6 PM EST, with occasional weekend and holiday shifts. This position is fully remote; however, you must reside in the Eastern Standard Time (EST) zone. Some travel to Humana offices for training or meetings may be necessary. Scheduled Weekly Hours: 40 Compensation: The starting salary for this full-time role is estimated between $71,100 and $97,800 per year, varying by geographic location and individual qualifications. This position is also eligible for a performance-based bonus incentive plan. Benefits Overview: At Humana, we offer competitive benefits aimed at promoting wellness and supporting you and your family outside of work. Our benefits include medical, dental, and vision coverage, a 401(k) retirement plan, generous paid time off, short- and long-term disability insurance, life insurance, and more. Application Deadline: January 21, 2026 About Us: Humana Inc. is committed to prioritizing health for our teammates, customers, and communities. Through our insurance and healthcare services, we strive to improve the quality of life for millions, including Medicare and Medicaid beneficiaries. Equal Opportunity Employer: Humana is an equal opportunity employer, dedicated to diversity and inclusion in our hiring practices.

Created: 2026-03-04