Clinical Auditor Registered Nurse Utilization Management

Humana Inc; Montana; Remote; USD 71,000 - 98,000; Full time

Job summary

Join Humana as a Clinical Auditor Registered Nurse, where you'll review compliance and utilization management activities to enhance health outcomes. This fully remote role offers competitive pay and requires an active RN license and strong clinical experience. Apply now to be part of a dynamic healthcare team dedicated to patient care and compliance.

Benefits

401(k) retirement savings plan

Medical, dental and vision benefits

Paid time off and volunteer time off

Short-term and long-term disability

Flexible scheduling

Qualifications

• Minimum 3 years of clinical nursing experience
• 1 year auditing or utilization management experience
• Ability to obtain additional state licenses

Responsibilities

• Conduct and summarize compliance audits
• Review utilization management activities
• Analyze data for operational metrics

Skills

Intermediate proficiency in Microsoft Office

Ability to work independently

Analytical skills

Education

Active Registered Nurse license

Bachelor's degree (BSN) preferred

Job description

Clinical Auditor Registered Nurse Utilization Management page is loaded

Clinical Auditor Registered Nurse Utilization Management

Apply locations Remote Nationwide time type Full time posted on Posted Yesterday job requisition id R-380402

Become a part of our caring community and help us put health first

The Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

T he Compliance Nurse 2 ensures mandatory reporting completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. 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

• Active Registered Nurse license in a state that is part of the Enhanced Nursing Licensure Compact(eNLC) compact without disciplinary action

• ability to obtain additional state licensures without restrictions

• Intermediate or better proficiency using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment

• Minimum of three, (3), years varied clinical nursing experience.

• Minimum of one, (1), year of experience auditing and/or performing case management or utilization management chart reviews

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

Preferred Qualifications

• Bachelor's, BSN

• Health Plan experience working with large carriers

• Previous Medicare/Medicaid experience a plus

• Previous experience in utilization management, case management, discharge planning and/or home health or rehab

• Certification in Case Management a plus (CCM)

• Experience working with MCG or InterQual guidelines

• MCG Certification

Additional Information

Workstyle: Remote work at Home

Location: Must reside in a state that is part of the Enhanced Nursing Licensure Compact(eNLC)

Schedule:

• Typically, Monday through Friday 8:30 – 6:00pm Eastern Time

• Flexible scheduling upon leader approval

Travel: 1 to 2 time annually to the local market office as needed for meetings

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

• 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 an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Modern Hire Voice 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. If you are selected for a first-round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn’t missed) inviting you to participate in a Modern Hire Voice interview. In this interview, you will listen to a set of interview questions over your phone, and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

SSN Alert

Humana values 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 [e-mail] with instructions on how to add the information into your official application on Humana’s secure website.

Ethics Section 1121 of the Louisiana Code of Governmental Ethics states that current or former agency heads or elected officials, board or commission members or public employees of the Louisiana Health Department (LDH) who work directly with LDH’s Medicaid Division cannot be considered for this opportunity. A separation of two (2) or more years from LDH is required for consideration. For more information please visit: Louisiana Board of Ethics (la.gov)

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 yearThis 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: 07-01-2025

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.