Nurse jobs at Highmark - 136 jobs

Become a part of our caring community and help us put health first The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment, and refers to internal stakeholders for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in various medical management systems. 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. Use your skills to make an impact Required Qualifications 2+ years Utilization Management experience Active RN license in the state(s) in which the nurse is required to practice Ability to be licensed in multiple states without restrictions A minimum of three years varied nursing experience Previous experience in utilization management, case management, discharge planning and/or home health or rehab Proficient with MS Office products including Word, Excel and Outlook 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 Preferred Qualifications Bachelor's degree Health Plan experience working with large carriers Previous Medicare/Medicaid experience a plus Outpatient or home health experience in Utilization Management Experience working with MCG or Interqual guidelines Additional Information Schedule: Monday through Friday, 8:00 AM - 5:00 PM with flexibility to work overtime/weekend as needed. Work Location: US Nationwide Work Style: Remote Travel Requirements: Less than 1% Work-at-Home (WAH) Internet Statement To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees 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 employees 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. Interview Format As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. 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: 01-19-2026 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.

Become a part of our caring community and help us put health first Humana Healthy Horizons in Indiana is seeking a Care Coordinator 2 (Field Care Manager 2) who assesses and evaluates member's needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. This position serves members of the new Indiana Medicaid program - Indiana PathWays for Aging (PathWays). The program was designed to help more Hoosiers who choose to age at home, do so, and to achieve better access to services, and better health and quality outcomes. You will be part of a caring community at Humana. When you meet us, you can tell we started as a hometown company. We are proud of our Louisville roots and, as we have grown, that community feeling has spread across all 50 states and Puerto Rico. No matter where you are-whether you are working from home, from the field, from our offices, or from somewhere in between-you will feel welcome here. We are a caring community made of close-knit teams, cross-country friendships, and inclusive resource groups, all gathered around one big table where everyone's voice is heard and respected. Community is a verb here. It is up to each of us to care for it and maintain it. Because the relationships we form will help us deliver better health outcomes for the people we so proudly serve. * Health Insurance begins on day one! * 23 days of vacation with pay per year * Aggressive 401K program matching 125% of 6% after year one! Are you caring, Curious and Committed? If so, apply today! Position Responsibilities: The Care Coordinator 2 employs a variety of strategies, approaches, and techniques to manage a member's physical, environmental, and psycho-social health issues. Identifies and resolves barriers that hinder effective care. Facilitate the development of a longitudinal and trusting relationship with each member toward improved quality, continuity, and coordination of care. Responsible for the coordination of all the member's needed medical and non-medical services, including functional, social, and environmental services. Works collaboratively with the Service Coordinator, Transition Coordinator, and other care team staff to address the member's identified needs Coordinates with all Medicare payers, Medicare Advantage plans, and Medicare providers as appropriate to coordinate the care and benefits of members who are also eligible for Medicare. Primary point of contact for the Interdisciplinary Care Team (ICT) and shall be responsible for coordinating with the member, ICT participants, and outside resources to ensure the member's needs are met. Use your skills to make an impact Required Qualifications Licensed Registered Nurse (RN) in the state of Indiana without restrictions At least one (2) years of clinical experience as a nurse in providing case management or similar health care services (internal note: could be LPN experience if relevant) Intermediate to advanced computer skills and experience with Microsoft Word, Excel, and Outlook. Exceptional communication and interpersonal skills with the ability to build rapport with internal and external customers and stakeholders. Proven ability of critical thinking, organization, written and verbal communication and problem- solving skills. Ability to manage multiple or competing priorities in a fast-paced environment. Ability to use a variety of electronic information applications/software programs including electronic medical records. Live/Reside in Indiana Preferred Qualifications Bilingual (English/Spanish) or (English/Burmese) Prior nursing home diversion, long-term care, disease management, or case management experience Prior management of Home and Community Based Services waivers (HCBS dual roles only) Prior experience with Medicare & Medicaid recipients Experience working with a geriatric population Experience with health promotion, coaching and wellness Knowledge of community health and social service agencies and additional community resources Additional Information About Humana Your growth is what drives Humana forward. When you get here, the journey is just beginning. Our leaders are committed to understanding what you need to grow. Because we do not grow without you This is a place where our nurses influence the C-suite. Where software engineers change lives. Where every associate can build a professional path where they learn and thrive. Through our commitments to wellbeing and work-life balance, we support each associate's personal health, purpose, work style, sense of belonging, and security. Because finding new ways to put health first-for our members and patients and our associates alike-is what we do. Additional Requirements/Adherence Workstyle: Combination remote work at home and onsite member visits Location: Must reside in Indiana Hours: Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, over-time may be requested to meet business needs. Travel: Must be willing to commute about 70% to meet with members. On Call-Telephonic on call for an occasional night and/or weekend may be required. Work at Home Guidance 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. 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. Driver's License, Transportation, Insurance This role is a part of Humana's Driver Safety program and therefore requires and individual to have: Valid state driver's license Proof of personal vehicle liability insurance with at least $100,000/$300,000/$100,000 limits Access to a reliable vehicle Tuberculosis (TB) screening program This role is considered patient facing and is part of Humana at Home's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB. Interview Format As part of our hiring process for this opportunity, we will be using an exciting screening and interviewing technology called Modern Hire to enhance our hiring and decision-making ability. We use this technology to gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. You will be able to respond to the recruiters preferred response method via text, video, or voice technologies. If you are selected for a screen, you may receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication is not missed) inviting you to participate. You should anticipate this screen to take about 15 to 30 minutes. Your recorded screen will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews. 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. 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.

Become a part of our caring community and help us put health first The Senior Stars Improvement, Clinical Professional responsible for the development, implementation and management oversight of the company's Medicare/Medicaid Stars Program. The Senior Stars Improvement, Clinical Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior Stars Improvement, Clinical Professional is responsible for a provider assignment of 50+ Medicaid provider groups. This position oversees HEDIS, quality & performance improvement and required quality activities that are related to NCQA health plan performance rating as well as the Agency's Quality Withhold and Liquidated Damages programs for assigned providers. Also supports improvement strategies through engagement with internal and external stakeholders. The Senior Stars Improvement, Clinical Professional monitors assigned value-based and non-value-based provider/provider groups' performance in key performance indicators related to preventive care, care of chronic conditions and identified medical metrics (ex. HEDIS, APT, readmissions, ED utilization, polypharmacy, etc.). In this role, you will actively engage providers, review of KPIs, improvement strategies and bi-directional feedback related to barriers and opportunities. Educate and assist providers in reducing potential preventable events through the use of data driven methods and resources related to available clinical programs. Support improvement in member experience through education, information and resources related to the annual Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and Humana's Member Experience Medicaid Survey (MEMS). Responsibilities: Continue to focus efforts and identify opportunities on performance improvement for assigned providers Actively engages provider during virtual visit to facilitate education, HEDIS outcomes, care of members and bi-directional feedback. Attends JOCs with providers and participates in active discussions on HEDIS, member care, and clinical/quality outcomes. Communicate clinical quality initiatives to assigned providers Educate and assist providers in reducing potential preventable events Educate providers and staff about Medicaid Consume Assessment of Healthcare Providers and Systems (CAHPS) survey. Use your skills to make an impact Required Qualifications FL RN License Must reside in the state of Florida Must have two years of prior HEDIS, STARS and/or quality improvement experience in Medicaid or Medicare (Medicaid quality improvement a plus). Proficient/ intermediate utilization of Excel and PowerPoint. Prior experience in a fast-paced insurance or health care setting Experience collaborating with cross-functional teams Proven analytical skills Excellent communication skills, both oral and written Strong relationship building skills Conducts self in a professional manner with all verbal and written communication when working with associates, peers, and providers Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred FL BSN License (Bachelor's Degree in Nursing) Medical Coding Certification Knowledge of Humana's internal policies, procedures, and systems Medicaid Health Plan Experience Additional Information Workstyle: Remote Work Location: Must reside in FL Travel: None Typical Workdays/Hours: Monday- Friday, 8am- 5pm EST 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. Interview Format As part of our hiring process for this opportunity, we will be using exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected for a first-round interview, you will receive an email correspondence inviting you to participate in a HireVue interview. In this interview, you will receive a set of interview questions over your phone, and you will provide recorded or text message responses to each question. For best interview experience use a computer over a phone. You should anticipate this interview to take about 15-20 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews. Humana Benefits Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security-both today and in the future, including: Health benefits effective day 1 Paid time off, holidays, volunteer time and jury duty pay Recognition pay 401(k) retirement savings plan with employer match Tuition assistance Scholarships for eligible dependents Parental and caregiver leave Employee charity matching program Network Resource Groups (NRGs) Career development opportunities Social Security Task Humana value's personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from ******************** with instructions on how to add the information into your official application on Humana's secure website. 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. $78,400 - $107,800 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. 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.

Become a part of our caring community and help us put health first The Senior Stars Improvement, Clinical Professional responsible for the development, implementation and management oversight of the company's Medicare/Medicaid Stars Program. The Senior Stars Improvement, Clinical Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior Stars Improvement Clinical Professional focused on maternal health is responsible for a provider assignment of 50+ Medicaid provider groups. This position oversees HEDIS, quality & performance improvement and required quality activities that are related to NCQA health plan performance rating as well as the Agency's Quality Withhold and Liquidated Damages programs for assigned providers. Also supports improvement strategies through engagement with internal and external stakeholders. The Senior Stars Improvement, Clinical Professional monitors assigned value-based and non-value-based provider/provider groups' performance in key performance indicators which may include preventive care, maternal health, and identified medical metrics (ex. HEDIS, admissions, readmissions, ED utilization, polypharmacy, pre-term delivery rate, cesarean section rate, etc.). In this role, you will actively engage providers, review KPIs, improvement strategies and bi-directional feedback related to barriers and opportunities. Educate and assist providers in reducing potential preventable events through the use of data driven methods and resources related to available clinical programs. Support improvement in member experience through education, information and resources related to the annual Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and Humana's Member Experience Medicaid Survey (MEMS). The Senior Stars Improvement, Clinical Professional will collaborate with internal stakeholders and leaders to analyze and inform strategies for improvement in maternal health outcomes for our members and the communities we serve. Responsibilities: Continue to focus efforts and identify opportunities on performance improvement for assigned providers Actively engages provider during routine virtual visits to facilitate education, HEDIS and medical metric outcomes, care of members and bi-directional feedback. Attends joint operating committee meetings (JOCs) with providers and participates in active discussions on HEDIS, member care, and clinical/quality outcomes. Communicate clinical quality initiatives to assigned providers Educate and assist providers in developing strategies to reduce potential preventable events Educate providers and staff about Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Actively engage with internal stakeholders, leaders and teams to analyze and inform improvement strategies to address maternal health outcomes. Engagement may include formal and informal discussions, in individual or group settings. Use your skills to make an impact Required Qualifications FL RN License Must reside in the state of Florida Must have quality improvement experience in Medicaid or Medicare (Medicaid quality improvement a plus) (i.e. HEDIS, CMS Stars) Proficient/ intermediate utilization of Excel and PowerPoint. Prior experience in a fast-paced insurance or health care setting Experience collaborating with cross-functional teams Proven analytical skills Excellent communication skills, both oral and written Strong relationship building skills Demonstrated ability to work independently, proactively initiate tasks, conduct thorough research, and acquire new knowledge to support ongoing development. Conducts self in a professional manner with all verbal and written communication when working with associates, peers, and providers Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications Bachelor's degree in nursing or related field Medical Coding Certification Certified Professional in Healthcare Quality (CPHQ) Knowledge of Humana's internal policies, procedures, and systems Medicaid Health Plan Experience Additional Information Workstyle: Remote Work Location: Must reside in FL Travel: None Typical Workdays/Hours: Monday- Friday, 8am- 5pm EST 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. Interview Format: As part of our hiring process for this opportunity, we will be using exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected for a first-round interview, you will receive an email correspondence inviting you to participate in a HireVue interview. In this interview, you will receive a set of interview questions you may answer via by phone or computer, and you will provide recorded or text message responses to each question. Some of the questions may require longer responses and using a computer vs phone to type responses may work best. You should anticipate this interview to take about 15-20 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews. Why Humana? At Humana, we know your well-being is important to you, and it's important to us too. That's why we're committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. Just to name a few: Work-Life Balance Generous PTO package Health benefits effective day 1 Annual Incentive Plan 401K - with company match Well-being program Paid Volunteer Time Off Student Loan Refinancing If you share our passion for helping people, we likely have the right place for you at Humana. Social Security Task: Alert: Humana values personal identity protection. Please be aware that applicants being considered for an offer will be asked to provide a social security number, if it is not already on file. When required, an email will be sent from ******************** with instructions to add the information into the application at Humana's secure website. 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. $78,400 - $107,800 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. 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.

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, discharges 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 at an on-site facility. This position will have a limited hybrid with some hours working at home at leader discretion. Candidate must be local, within about a 30-minute driving distance to HCA St. Lucie Medical Center, in Palm Beach County, from home base. The Utilization Management Nurse 2 is an Onsite Nurse located at HCA St. Lucie Medical Center who 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 our Medicare members. Coordinate and communicate with providers, members, case managers PCP or other parties to facilitate appropriate discharge planning, assist with social determinants and closing gaps to facilitate optimal care and treatment. Identify barriers to discharge and avoidable readmissions Understands department, segment, and organizational strategy and operating objectives, including how they interrelate to each area Works independently, makes appropriate decisions, requires minimal direction and seeks guidance where needed Evaluate and refer to other programs available to Member Follows established guidelines/procedures ** This is an Onsite / Hybrid position at HCA St. Lucie Medical Center, located in St. Lucie, Florida. The ideal candidate must be located no more than a 30-minutes driving distance to the Onsite location from their home base. This position will work at an Onsite facility and as a Hybrid, will have limited working hours at home based on the leader's discretion. ** Use your skills to make an impact Required Qualifications RN License without restrictions in the state of Florida Must be located no more than 30-minutes driving distance to HCA St. Lucie Medical Center from home base 2 or more years of clinical experience preferably in an adult/geriatric acute care, skilled or rehabilitation clinical setting Comprehensive knowledge of Microsoft Word, Outlook and Excel Ability to work independently under general instructions and with a team. Independent critical thinking skills Strong written and verbal communication skills Valid Driver's License and/or dependable transportation necessary Travel to Hospital/Provider for onsite reviews to assist Members This role is considered patient facing. If selected for this role, you will be required to meet criteria to be onsite with Providers/Hospitals/Health Care Facilities This hybrid position will have limited hours working at home at the leader's discretion This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB Preferred Qualifications Bachelor's degree in nursing (BSN) Previous experience in discharge planning, utilization management or case management a plus Health Plan experience Previous Medicare/Geriatric Experience a plus Bilingual is a plus 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 Scheduled Weekly Hours Full time position 40 hour work week Must be able to work 8:30 am-5pm EST Monday-Friday 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. 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.

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: 01-21-2026 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.

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.The UM Nurse 2 will- Uses clinical knowledge, communication skills, and independent critical thinking skills towards:. Interpreting criteria, policies, and procedures related to Long Term Services and Support authorizations to provide the best and most appropriate treatment, care, or services for members. Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. Understand department and organizational strategy and operating objectives, including their linkages to related areas. Follow established guidelines/procedures. Make decisions regarding own work methods, occasionally in ambiguous situations, requires minimal direction and receives guidance where needed. Use your skills to make an impact REQUIRED QUALIFICATIONS: Must reside in Michigan or within 40 miles of the border in Indiana or Ohio. Active Registered Nurse (RN) in the state of Michigan with no disciplinary action. 1-year previous experience in utilization management/LTSS service authorization. At least 2 years prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting, or Medicaid Managed Care Organization. Comprehensive knowledge of Microsoft Word, Outlook and Excel. Ability to work independently under general instructions and with a team. 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. PREFERRED QUALIFICATIONS: Bachelor's or Associate's Degree in Nursing or other related field. Previous Medicare/Medicaid experience. NCQA, CM experience. Previous experience in discharge planning and/or home health or rehabilitation. Bilingual preferred (Spanish, Arabic, Chaldean Neo-Aramaic or other). ADDITIONAL INFORMATION: Workstyle: This is a remote position. Travel: May need to attend onsite meetings Workdays and Hours: Monday - Friday; 8:00am - 5:00pm Eastern Standard Time (EST). Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. WAH INTERNET STATEMENT: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Humana will provide Home or Hybrid Home/Office employees 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. Interview Process As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. Assessment: If you are selected to move forward, you will receive an email to complete the Virtual Job Experience (VJE). This is an online activity where you will learn more about Customer Care jobs at Humana, try out some of the most common job tasks, and tell us more about yourself. Most people complete the VJE in approximately 30 minutes. To complete it, you will need a smart phone, computer or tablet with internet access, and speakers/headphones. We do not make job offers to candidates that do not complete the VJE. Video Prescreen: If you are successful with your text screen, you will receive another communication to record a Video Prescreen. This is an online video activity using your phone, tablet, or computer; however, most candidates prefer using a computer or tablet. Interviews: Some candidates will be invited to interview. If so, the recruiter will reach out to schedule. Offers: Finalists from the interview will be contacted by a recruiter to discuss an offer for the job Note: Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed. 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. 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.

**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 businessinvolving expedited, pre-service and post serviceappeals + 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: 01-21-2026 **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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************

**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. The UM Nurse 2 will- + Uses clinical knowledge, communication skills, and independent critical thinking skills towards:. + Interpreting criteria, policies, and procedures related to Long Term Services and Support authorizations to provide the best and most appropriate treatment, care, or services for members. + Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. + Understand department and organizational strategy and operating objectives, including their linkages to related areas. + Follow established guidelines/procedures. + Make decisions regarding own work methods, occasionally in ambiguous situations, requires minimal direction and receives guidance where needed. **Use your skills to make an impact** **REQUIRED QUALIFICATIONS:** + **Must reside in Michigan or within 40 miles of the border in Indiana or Ohio** . + Active Registered Nurse (RN) in the state of Michigan with no disciplinary action. + 1-year previous experience in utilization management/LTSS service authorization. + At least 2 years prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting, or Medicaid Managed Care Organization. + Comprehensive knowledge of Microsoft Word, Outlook and Excel. + Ability to work independently under general instructions and with a team. + 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. **PREFERRED QUALIFICATIONS:** + Bachelor's or Associate's Degree in Nursing or other related field. + Previous Medicare/Medicaid experience. + NCQA, CM experience. + Previous experience in discharge planning and/or home health or rehabilitation. + Bilingual preferred (Spanish, Arabic, Chaldean Neo-Aramaic or other). **ADDITIONAL INFORMATION:** + Workstyle: This is a remote position. + Travel: May need to attend onsite meetings + Workdays and Hours: Monday - Friday; 8:00am - 5:00pm Eastern Standard Time (EST). + Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. **WAH INTERNET STATEMENT:** To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. + Satellite, cellular and microwave connection can be used only if approved by leadership. + Humana will provide Home or Hybrid Home/Office employees 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. **Interview Process** As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. **Assessment:** If you are selected to move forward, you will receive an email to complete the Virtual Job Experience (VJE). This is an online activity where you will learn more about Customer Care jobs at Humana, try out some of the most common job tasks, and tell us more about yourself. Most people complete the VJE in approximately 30 minutes. To complete it, you will need a smart phone, computer or tablet with internet access, and speakers/headphones. We do not make job offers to candidates that do not complete the VJE. **Video Prescreen** : If you are successful with your text screen, you will receive another communication to record a Video Prescreen. This is an online video activity using your phone, tablet, or computer; however, most candidates prefer using a computer or tablet. **Interviews** : Some candidates will be invited to interview. If so, the recruiter will reach out to schedule. **Offers** : Finalists from the interview will be contacted by a recruiter to discuss an offer for the job **Note** : Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed. 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. **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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************

**Become a part of our caring community and help us put health first** The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment, and refers to internal stakeholders for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in various medical management systems. 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. **Use your skills to make an impact** **Required Qualifications** + 2+ years Utilization Management experience + Active RN license in the state(s) in which the nurse is required to practice + Ability to be licensed in multiple states without restrictions + A minimum of three years varied nursing experience + Previous experience in utilization management, case management, discharge planning and/or home health or rehab + Proficient with MS Office products including Word, Excel and Outlook + 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 **Preferred Qualifications** + Bachelor's degree + Health Plan experience working with large carriers + Previous Medicare/Medicaid experience a plus + Outpatient or home health experience in Utilization Management + Experience working with MCG or Interqual guidelines **Additional Information** + **Schedule** : Monday through Friday, 8:00 AM - 5:00 PM with flexibility to work overtime/weekend as needed. + **Work Location:** US Nationwide + **Work Style:** Remote + **Travel Requirements** **: Less than 1%** **Work-at-Home (WAH) Internet Statement** To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. + Satellite, cellular and microwave connection can be used only if approved by leadership. + Employees 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 employees 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. **Interview Format** As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. 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: 01-19-2026 **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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Location: Position is remote. Prefer candidate to live in PST time zone. Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST. Position Purpose: Oversees correspondence letters based and supports overall team needs. Reviews outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Oversees the clinical review of outcomes including creating and editing correspondence letters with the correspondence team based on determinations in accordance with National Committee for Quality Assurance (NCQA) standards Manages the audits of correspondence to ensure they are processed in accordance with Federal, State, and NCQA standards Provides expert insight and guidance on the clinical review process of correspondence to ensure compliance with all applicable State and Federal regulations Provides subject matter expertise insights to investigate and resolve issues including comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and escalates as appropriate to resolve issues in a timely manner Acts as a point of contact for escalated, advanced issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer and providers to ensure issues are resolved in a timely manner Oversees clinical quality and process improvement initiatives related to clinical quality indicators and financial metrics Manages data needed to identify trends and provide recommendations to senior management of process improvements within utilization management Manages and oversees cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Provides training and education to the interdepartmental teams on training needed within the utilization management team based on trends Partners with leadership to improve processes and procedures to prevent recurrences based on industry best practices Provides guidance, subject matter expertise and training as needed Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 5 - 7 years of related experience. Expert knowledge of Medicare and Medicaid regulations preferred. Expert knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required- Compact License Location: Position is remote. Prefer candidate to live in PST time zone. Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST. Pay Range: $35.49 - $63.79 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

**Explore opportunities with [agency name],** a part of LHC Group, a leading post-acute care partner for hospitals, physicians and families nationwide. As members of the Optum family of businesses, we are dedicated to helping people feel their best, including our team members who create meaningful connections with patients, their families, each other and the communities we serve. Find a home for your career here. Join us and embrace a culture of **Caring. Connecting. Growing together.** As the Registered Nurse you will provide and direct provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations, and agency policies. You will also coordinate total plan of care with other health care professionals involved in care and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. **Primary Responsibilities:** + Provide high-quality clinical services within scope of practice and infection control standards + Coordinate care with other members of the patient/client's care team from admission to discharge + Complete clinical nursing assessments per federal/state program requirements and payer needs + Ensure patient/client eligibility and medical necessity for services as defined by payer and agency policy + Develop and revise individualized plans of care/service plans with other community providers + Ensure plan of care frequency and duration meets patient needs and initiate revisions with physician approval You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Current and unrestricted RN licensure in the state of practice + Current driver's license, vehicle insurance and access to a dependable vehicle or public transportation + Current CPR certification + Ability to function in any home situation regardless of age, race, creed, color, sex, disability, or financial condition of the client **State Specific Requirements:** + LA: + 1+ years of clinical experience as a Registered Nurse + 1+ years of clinical experience as a Registered Nurse + 1+ years of clinical experience as a Registered Nurse may be waived for a Registered Nurse with recent clinical experience as an LPN + RN licensure must have no restrictions **Preferred Qualifications:** + 1+ years of RN experience + Able to work independently + Good communication, writing, and organizational skills *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. **Application Deadline:** This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._

Explore opportunities with [agency name], a part of LHC Group, a leading post-acute care partner for hospitals, physicians and families nationwide. As members of the Optum family of businesses, we are dedicated to helping people feel their best, including our team members who create meaningful connections with patients, their families, each other and the communities we serve. Find a home for your career here. Join us and embrace a culture of Caring. Connecting. Growing together. As the Registered Nurse you will provide and direct provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations, and agency policies. You will also coordinate total plan of care with other health care professionals involved in care and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: * Provide high-quality clinical services within scope of practice and infection control standards * Coordinate care with other members of the patient/client's care team from admission to discharge * Complete clinical nursing assessments per federal/state program requirements and payer needs * Ensure patient/client eligibility and medical necessity for services as defined by payer and agency policy * Develop and revise individualized plans of care/service plans with other community providers * Ensure plan of care frequency and duration meets patient needs and initiate revisions with physician approval You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * Current and unrestricted RN licensure in the state of practice * Current driver's license, vehicle insurance and access to a dependable vehicle or public transportation * Current CPR certification * Ability to function in any home situation regardless of age, race, creed, color, sex, disability, or financial condition of the client State Specific Requirements: * LA: * 1+ years of clinical experience as a Registered Nurse * 1+ years of clinical experience as a Registered Nurse * 1+ years of clinical experience as a Registered Nurse may be waived for a Registered Nurse with recent clinical experience as an LPN * RN licensure must have no restrictions Preferred Qualifications: * 1+ years of RN experience * Able to work independently * Good communication, writing, and organizational skills * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. This is a 100% remote role. Must have a Oregon LPN or RN license. One of the following shifts will be needed: Sunday - Thursday 8-5pm OR 9-6pm Tuesday - Saturday 8-5pm OR 9-6pm Friday - Monday 10 hour shifts Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards This is a 100% remote role. One of the following shifts will be needed: Sunday - Thursday 8-5pm OR 9-6pm Tuesday - Saturday 8-5pm OR 9-6pm Friday - Monday 10 hour shifts Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required - Must have an Oregon license Registered Nurse - Must have an Oregon license This is a 100% remote role. One of the following shifts will be needed: Sunday - Thursday 8-5pm OR 9-6pm Tuesday - Saturday 8-5pm OR 9-6pm Friday - Monday 10 hour shifts Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs a clinical retrospective review of services previously provided to determine if the level of care and services provided were clinically appropriate. Provides observations to senior management for quality-of-care issues identified to ensure services were administered with quality, cost efficiency, and are within compliance. Performs a clinical review of post-care services by reviewing medical records against guidelines and clinical research criteria to determine if the services administered were clinically appropriate and within quality standards at the most efficient and effective level Reviews medical records for medical necessity of services, to identify quality of care issues, and if identified, refer to the Medical Director or provider for review and verification Consults with senior management and healthcare providers, as appropriate, for any discrepancies between prior authorization and concurrent review processes to ensure clinically appropriate determinations Collects, documents, and maintains all member's clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers on utilization processes to promote high quality, cost-effective, and efficient medical care to members Provides feedback on opportunities to improve the retrospective review process for members and to ensures high quality care Performs other duties as assigned Complies with all policies and standards Location: Remote (Must be able to work in Central Time Zone) Ideal candidate will have experience in payment integrity and utilization review. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. Clinical knowledge and ability to analyze medical records to determine care services provided were appropriate preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

**Explore opportunities** with a part of LHC Group, a leading post-acute care partner for hospitals, physicians and families nationwide. As members of the Optum family of businesses, we are dedicated to helping people feel their best, including our team members who create meaningful connections with patients, their families, each other and the communities we serve. Find a home for your career here. Join us and embrace a culture of **Caring. Connecting. Growing together.** As the Registered Nurse you will provide and direct provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations, and agency policies. You will also coordinate total plan of care with other health care professionals involved in care and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. **Primary Responsibilities:** + Provide high-quality clinical services within scope of practice and infection control standards + Coordinate care with other members of the patient/client's care team from admission to discharge + Complete clinical nursing assessments per federal/state program requirements and payer needs + Ensure patient/client eligibility and medical necessity for services as defined by payer and agency policy + Develop and revise individualized plans of care/service plans with other community providers + Ensure plan of care frequency and duration meets patient needs and initiate revisions with physician approval You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Current and unrestricted RN licensure in the state of practice + Current driver's license, vehicle insurance and access to a dependable vehicle or public transportation + Ability to function in any home situation regardless of age, race, creed, color, sex, disability, or financial condition of the client **State Specific Requirement:** + CA: 1+ years of experience in professional nursing **Preferred Qualifications:** + Able to work independently + Good communication, writing, and organizational skills Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together We are currently seeking an experienced RN with strong interpersonal skills to join our team. The chosen Clinical Appeals & Coding RN would be responsible for reviewing appeals and grievances to determine if the appropriate care was given. In providing Medicaid Community and State provider post service appeals. Our goal is to create higher quality care, lower costs and greater access to health care. Join us, and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: * Clinical Appeals and Grievances (analyzing, reviewing appeals / grievances) * Review of coding edits and reimbursement issues * Works with less structured, more complex issues * Solves moderately complex problems and / or conducts moderately complex analyses * Translates concepts into practice * Assesses and interprets customer needs and requirements * Identifies solutions to non-standard requests and problems * Works with minimal guidance; seeks guidance on only the most complex tasks * Works with less structured, more complex issues * Coaches, provides feedback and guides others You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * Active unrestricted RN license in state of TN * 3+ years clinical experience in a hospital, acute care or direct care setting * Experience in reviewing coding edits (CPT) and reimbursement issues * Medical record review / appeal review experience * Experience working in a managed care environment (insurance company or medical group) * Proficient level of experience with Microsoft Office Suite (Word, Excel & Outlook) * Proven ability to adapt to change & work in a high volume environment * Proven outstanding coding skills with hands-on experience with coding edits &reimbursement issues * Proven solid critical thinking, analytical and research skills * Ability to work Monday - Friday from 8:30am - 5:00pm within your time zone Preferred Qualifications: * CPC (Certified Professional Coder) * Utilization Review experience * Clinical Chart Reviews * Post Service Provider Denial experience * Knowledge of Medicare / Medicaid regulations * All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.63 per hour based on full-time employment. We comply with all minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

**Explore opportunities with the LHC** **Group** , a leading post-acute care partner for hospitals, physicians and families nationwide. As members of the Optum family of businesses, we are dedicated to helping people feel their best, including our team members who create meaningful connections with patients, their families, each other and the communities we serve. Find a home for your career here. Join us and embrace a culture of **Caring. Connecting. Growing together.** As the Registered Nurse you will provide and direct provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations, and agency policies. You will also coordinate total plan of care with other health care professionals involved in care and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. **Primary Responsibilities:** + Provide high-quality clinical services within scope of practice and infection control standards + Coordinate care with other members of the patient/client's care team from admission to discharge + Complete clinical nursing assessments per federal/state program requirements and payer needs + Ensure patient/client eligibility and medical necessity for services as defined by payer and agency policy + Develop and revise individualized plans of care/service plans with other community providers + Ensure plan of care frequency and duration meets patient needs and initiate revisions with physician approval You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Current and unrestricted RN licensure in the state of practice + Current driver's license, vehicle insurance and access to a dependable vehicle or public transportation + Ability to function in any home situation regardless of age, race, creed, color, sex, disability, or financial condition of the client **Preferred Qualifications:** + 1+ years of RN experience + Current CPR certification + Able to work independently + Good communication, writing, and organizational skills Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. _At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._ _UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._

Explore opportunities with the LHC Group, a leading post-acute care partner for hospitals, physicians and families nationwide. As members of the Optum family of businesses, we are dedicated to helping people feel their best, including our team members who create meaningful connections with patients, their families, each other and the communities we serve. Find a home for your career here. Join us and embrace a culture of Caring. Connecting. Growing together. As the Registered Nurse you will provide and direct provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations, and agency policies. You will also coordinate total plan of care with other health care professionals involved in care and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. Primary Responsibilities: * Provide high-quality clinical services within scope of practice and infection control standards * Coordinate care with other members of the patient/client's care team from admission to discharge * Complete clinical nursing assessments per federal/state program requirements and payer needs * Ensure patient/client eligibility and medical necessity for services as defined by payer and agency policy * Develop and revise individualized plans of care/service plans with other community providers * Ensure plan of care frequency and duration meets patient needs and initiate revisions with physician approval You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * Current and unrestricted RN licensure in the state of practice * Current driver's license, vehicle insurance and access to a dependable vehicle or public transportation * Ability to function in any home situation regardless of age, race, creed, color, sex, disability, or financial condition of the client Preferred Qualifications: * 1+ years of RN experience * Current CPR certification * Able to work independently * Good communication, writing, and organizational skills Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.