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Humana Manager, Utilization Management Nursing - Medicare / Medicaid in San Juan, Puerto Rico


The Manager, Utilization Management Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Manager, Utilization Management Nursing works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.


Humana is a Fortune 60 healthcare company with a history of successful innovation and reinvention, with over 50 years as a proven leader and innovator in the health and wellness industry. A passionate emphasis on people, choice, well-being, and innovation guide our business and culture. We're not just a health insurance company: our diverse lines of business position us to serve millions of people with a wide range of needs, including seniors, military members, and self-employed individuals.

Our leaders are passionate clinical leaders that have a strong desire to empower their teams to improve the quality and timeliness of health care for the patients we serve.

This leader should have a strong foundation in Utilization Management, ideally focused on the Medicare and/or Medicaid populations. Our UM model incorporates the patient's primary care physician back into the decision making for the patients, allowing our nurses additional opportunity to advocate for the patients throughout their care continuum. Experience working within a Value Base Care model is preferred. Utilizing clinical skills to support the coordination, documentation and communication within specific guidelines and procedures is a must. In addition to the oversight of their team this associate will play a key role in relationship development with the provider organizations we currently support.

This role requires the ability to develop and maintain cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other leaders both internal and external partners. Allowing the opportunity to for this leader to facilitate changes that will help us continue to evolve the ways we can support our patients and clinicians.

Full time associates enjoy:   

  • Base salary with a competitive commission structure and a monthly guarantee   * Medical, Dental, Vision and a variety of other supplemental insurances  

  • Paid time off (PTO) & Paid Holidays  

  • 401(k) retirement savings plan with a competitive match  

  • Tuition reimbursement and/or scholarships for qualifying dependent children

  • And much more! 

Required Qualifications

  • Bachelor's Degree or equivalent in Nursing

  • 6+ years of technical experience

  • 4+ years of utilization management experience

  • Licensed Registered Nurse (RN) in the state in which you reside, with no disciplinary action

  • Progressive clinical experience preferably in an acute care, skilled or rehabilitation clinical setting

  • 2+ years of experience leading a team of clinicians

  • Ability to navigate change management in a rapidly evolving Utilization Management program

Preferred Qualifications

  • Previous experience working in a Value Based Care Model

  • Care coordination experience

  • Health Plan experience

  • Prior Medicare / Medicaid experience

  • Call center or triage experience

  • Bilingual is a plus

Additional Information

Interview Format:

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire Text to enhance our hiring and decision-making ability. Modern Hire Text 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 Modern Hire text interview. In this interview, you will read to a set of interview questions and you will provide text responses to each question. You should anticipate this interview to take about 15 minutes. Your text interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may 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.

Humana is more than an equal opportunity employer, Humana's dedication to promoting diversity, multiculturalism, and inclusion is at the heart of what we do in all of our Humana roles. Diversity is more than a commitment to us, it is the foundation of what we do. We are fully focused on diversity of race, gender, sexual orientation, religion, ethnicity, national origin and all of the other fascinating characteristics that make us each uniquely wonderful.

Scheduled Weekly Hours