Perform medical necessity reviews and authorization decisions for the Kentucky Medicaid Plan using clinical criteria. Facilitate proactive discharge planning and coordinate care between providers and members to ensure optimal treatment.
Become a part of our caring community The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations for Humana’s Kentucky Medicaid Plan.
This role has primary responsibility for performing medical necessity reviews, including initial and concurrent authorization decisions, using established clinical criteria and independent clinical judgment.
The Utilization Management Nurse 2 also plays a key role in facilitating comprehensive, proactive, and barrier-focused discharge planning to home or a lower level of care.
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.
Maintain compliance with state regulations and organizational standards for coordinated member discharge, ensuring all plans are documented and communicated effectively.
Perform initial and concurrent reviews with medical necessity determinations, including level of care and length of stay decisions.
Engage providers via telephonic, virtual, and onsite collaboration as needed.
Follows established guidelines/procedures.
The schedule for this position will include weekends, typically Wednesday through Sunday from 8:00 AM to 5:00 PM Eastern Time with flexibility to adjust weekdays off with leader approval.
Use your skills to make an impact Required Qualifications Licensed Registered Nurse (RN) in the state of Kentucky, in good standing with no disciplinary action.
2+ years of progressive clinical experience in an acute care, skilled nursing, or rehabilitation setting (preferred).
1+ year of utilization management experience.
Maintain compliance with state regulations and organizational standards, ensuring that we coordinate and document member discharge plans and communicate them.
Experience performing initial and concurrent reviews for medical service requests, with the ability to interpret clinical criteria and apply judgment to support appropriate use and benefit administration.
Experience engaging with providers and care teams through telephonic, virtual, or onsite interactions to facilitate authorizations and support member-centered discharge planning.
Strong proficiency in Microsoft Office Suite, including Word, Excel, and PowerPoint.
Bachelor's degree in nursing. MCG experience. Experience in discharge planning, transitions of care, and familiarity with community-based resources and social determinants of health. Health plan experience. Medicaid experience. Bilingual in English and another language. A Language Proficiency Assessment will be conducted to evaluate fluency in reading, writing, and speaking in both languages prior to assignment to a dedicated member service line.
Workstyle: Remote work at home Location: Must reside in Kentucky or a county that is within contiguous bordering states Schedule: The schedule for this position will include weekends (Weekend shifts are eligible for a shift differential), from 8:00 AM to 5:00 PM Eastern Time with flexibility to adjust weekdays off with leader approval: The position follows a 5-day workweek, which includes both Saturday and Sunday. Associates will receive two days off during the week. Associates may choose which two weekdays they would like off. Once selected, those days off must remain consistent from week to week and cannot vary.
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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and 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.
Requires a valid Kentucky RN license and at least one year of utilization management experience. Preferred qualifications include a Bachelor's degree in nursing and experience with MCG or Medicaid plans.
Market context
Kentucky nursing employers commonly look for licensed practical nurses who can step into school, pediatric, or long-term care settings and handle routine care with confidence. These roles can be competitive because an active Kentucky LPN license, current CPR/BLS, and comfort with complex medical needs are often expected, while the benefits package may include paid holidays, personal time, sick time, and a 401(k) match. Review the AI-summarized requirements and benefits here to save research time, and confirm your license and certification status before applying.
