Job Overview
Location
Remote Michigan
Job Type
Full-time
Category
HR & Recruiting
Date Posted
July 10, 2026
Full Job Description
đź“‹ Description
- • Utilization Management Nurse Lead uses clinical knowledge, communication skills, and independent critical thinking skills to interpret data, criteria, policies, and procedures 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.
- • Accountable, in partnership with the Chief Medical Officer (CMO), to analyze utilization management (UM) trends and drivers impacting member outcomes and financial impact.
- • Support quality efforts both at the market and enterprise level, achieving quality targets in HEDIS, STARS, and NCQA accreditation.
- • Advise executives to develop functional strategies on matters of significance.
- • Exercise independent judgment and decision making on complex issues regarding job responsibilities and related tasks, and work under minimal supervision, using independent judgment requiring analysis of variable factors and determining the best course of action.
- • Serve as a liaison between Humana UM operations and the State of Michigan regarding prior authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.
- • Coordinate with Humana’s Clinical Leadership teams to ensure utilization reviews comply with Centers for Medicare & Medicaid Services (CMS) regulations as well as Michigan Dual Special Needs Plan (DSNP) Contract terms.
- • Work in conjunction with the Quality Improvement Director to develop quantifiable metrics that can track and evaluate the results of the targeted interventions designed to reduce health disparities and address health inequities.
- • Manage Michigan state reporting and collaborate with the UM operations teams to aggregate and analyze data and reporting metrics.
- • Provide quality support to the supervision and daily guidance of prior authorization associates ensuring outcomes that meet or exceed Humana and the Michigan Department of Health and Human Services (MDHHS) standards.
- • Work in conjunction with Humana’s Medicare UM Committees to ensure adoption and consistent application of appropriate medical necessity criteria.
- • Participate in oversight of the programs to ensure that Enrollees are accessing and utilizing services in an appropriate manner in accordance with all applicable rule and regulations.
- • In conjunction with Humana’s UM monitoring and oversight processes, monitors and analyzes Michigan DSNP specific outcomes.
- • Ensure development and implementation of departmental policies and procedures in accordance with contract changes or updates.
- • Provide oversight to ensure Humana maintains compliance with MDHHS, National Committee for Quality Assurance (NCQA), Department of Health and Human Services (DHHS), CMS guidelines and contractual requirements.
🎯 Requirements
- • Must reside in or be willing to relocate to the state of Michigan.
- • An active, unrestricted registered nurse (RN) license in the state of Michigan.
- • Bachelor’s or associate degree in nursing, health services, healthcare administration, business administration or a related field.
- • Minimum five (5) years of clinical experience in utilization management.
- • Minimum two (2) years of formal or informal leadership experience.
🏖️ Benefits
- • Medical, dental and vision benefits.
- • 401(k) retirement savings plan.
- • Time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
- • Short-term and long-term disability.
- • Life insurance.
Skills & Technologies
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About Humana Inc.
Humana Inc. is a for-profit health and well-being company headquartered in Louisville, Kentucky. Founded in 1961, it provides health insurance, Medicare Advantage plans, Medicaid services, pharmacy benefit management, and clinical care through primary care centers. Serving millions of members across the United States, Humana focuses on integrated care delivery, home health, and wellness programs aimed at improving health outcomes and reducing costs for individuals, employers, and government partners.
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