Nurse for Utilization Management Appeals

Join Our Caring Community and Prioritize Health

The Nurse for Utilization Management Appeals plays a critical role in the coordination, documentation, and communication of medical services and benefit determinations. This position involves varied assignments that require independent decision-making and interpretation of appropriate actions.

As a G&A Nurse at Humana, you will prepare cases for review by our Medicare Medical Directors. You will review medical documentation, research claims, and prior determinations related to appeals while providing a detailed written summary of findings. You will collaborate with various teams, including Humana CIT teams, vendors, G&A specialists, and medical directors to enhance member outcomes and operational efficiencies.

• Prepare cases for the Medicare and Duals lines of business related to expedited, pre-service, and post-service appeals

• Implement Medicare, Medicaid, MCG, claims policy, and evidence of coverage guidelines during reviews

• Engage in outreach to providers and members

• Utilize multiple systems, including MHK, CGX, MRM, and SRO

Make a Significant Impact with Your Skills

Required Qualifications:

• Current Registered Nurse (RN) license in your state with no disciplinary actions

• At least 3 years of clinical experience, preferably in acute care, skilled nursing, or rehabilitation settings

• Proficient in Microsoft Word, Outlook, and Excel

• Excellent organizational and time management capabilities

• Ability to work independently and collaboratively

Preferred Qualifications:

• Bachelor's degree in Nursing (BSN)

• Experience with appeal reviews

• Familiarity with MHK

• Experience in Medicare/Medicaid

• Background in utilization management

• Claims experience

Work-from-Home Guidelines:

To ensure effective performance from a home or hybrid office, your internet service must meet the following criteria:

• A minimum download speed of 25 Mbps and an upload speed of 10 Mbps; a wired, DSL, or cable connection is recommended

• Satellite, cellular, and microwave connections may only be used with management approval

• Associates in California, Illinois, Montana, or South Dakota will receive bi-weekly reimbursements for internet costs

• Humana will supply the necessary telephone equipment for job performance

• Work from a dedicated, uninterrupted space to maintain member privacy and comply with HIPAA

Additional Information:

• Hours: Monday-Friday, 9 AM - 6 PM EST, with occasional weekend rotation and holiday shifts

• Remote employees must reside in the Eastern Standard Time (EST) zone

• Some travel to Humana offices for training or meetings may be required

Scheduled Weekly Hours: 40

Compensation: The starting salary for this full-time role is estimated between $71,100 and $97,800 per year, based on geographic location and individual qualifications. This position is also eligible for a bonus incentive plan based on performance metrics.

Benefits Overview:

At Humana, we offer competitive benefits designed to promote wellness and support you and your family outside of work. 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 much more.

Application Deadline: January 21, 2026

About Us:

Humana Inc. is dedicated to prioritizing health for our teammates, customers, and communities. Through our insurance and healthcare services, we strive to enhance the quality of life for millions, including Medicare and Medicaid beneficiaries.

Equal Opportunity Employer: Humana is an equal opportunity employer committed to diversity and inclusion in our hiring practices.