Utilization Management RN - Payer Operations

🔍 What we're looking for: Humata Health Inc. is seeking a Clinical Nurse to join our team and work at the intersection of healthcare and AI technology. In this role, you will collaborate with clients composed of health plan utilization review nurses and internal teams to ensure that our AI systems accurately support medical necessity decisions and prior authorization reviews. A key part of the workflow involves digitizing medical policies so that AI can interpret and apply them consistently — but the larger mission is to leverage clinical expertise to make prior authorization faster, smarter, and more reliable.

This position also requires project management skills to coordinate policy digitization efforts, track progress across multiple health plans, and manage timelines and deliverables with cross-functional teams.

Location: Remote, US or Hybrid - Orlando, Florida, US

Key Responsibilities

• Partner with health plan utilization review nurses to validate and improve AI-driven prior authorization workflows.

• Review and structure medical policies to enable AI-powered automation of utilization review decisions.

• Apply clinical judgment to ensure that AI outputs align with evidence-based guidelines, payer standards, and medical coding practices.

• Participate in product review cycles by providing feedback on usability, accuracy, and workflow alignment.

• Guide product teams by translating clinical and utilization review needs into actionable product requirements.

• Collaborate with product and engineering teams to refine how clinical decision points are represented in AI models.

• Test, validate, and continuously improve AI-enabled review tools for accuracy and fairness.

• Provide feedback to enhance both policy digitization workflows and AI-driven decision support.

• Manage small-scale projects, including organizing digitization initiatives, tracking timelines, coordinating stakeholders, and reporting on progress.

• Stay current on payer requirements, clinical guidelines, regulatory standards, and coding updates relevant to utilization management.

Qualifications

• Registered Nurse (RN) with an active license.

• 3+ years of experience in utilization management, prior authorization, case management, or related clinical roles.

• Strong understanding of payer policies, medical necessity criteria, and the prior authorization process.

• Working knowledge of medical coding systems (ICD-10, CPT, HCPCS).

• Comfort working with technology platforms; interest or experience in AI, clinical decision support, or health tech is a plus.

• Demonstrated project management skills — ability to organize complex workflows, manage deliverables, and ensure accountability across teams.

• Excellent critical thinking and problem-solving skills.

• Strong communication and collaboration abilities across clinical and technical teams.

Preferred Skills

• Certification in medical coding (e.g., CPC, CCS, CCA, or equivalent).

• Experience reviewing or implementing medical policies in a payer or managed care setting.

• Familiarity with health informatics, evidence-based guideline development, or digital clinical tools.

• Background in leading cross-functional projects or initiatives (formal project management certification is a plus).

• Experience working with AI, automation tools, or clinical decision support systems.

• Ability to work in a fast-paced, innovative environment and contribute to process improvement.

🚀 Why Join Humata Health?

• Impactful Work: Contribute to innovative solutions that improve healthcare efficiency and patient outcomes

• Remote Flexibility: Enjoy working remotely while being part of a collaborative team, with access to our new office in Winter Park, FL

• Competitive Compensation: Enjoy competitive base compensation, equity through our Employee Stock Option Plan, and bonus-eligible roles

• Comprehensive Benefits: Full benefits package including unlimited PTO and 401k program with employer match

• Growth Opportunities: Advance your career in a fast-paced, high-impact environment with ample professional development

• Inclusive Culture: Join a diverse workplace where your ideas and contributions are valued

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Pay Transparency

Humata Health will provide pay transparency information upon application to those in qualifying jurisdictions.

Our salary ranges are based on competitive pay for our company’s size and industry. They are one part of the total compensation package that may also include equity, variable compensation, and benefits.  Individual pay decisions are ultimately based on several factors, including qualifications, experience level, skillset, geography, and balancing internal equity.

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Humata Health is proud to be an equal-opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, age, sex, marital status, ancestry, neurotype, physical or mental disability, veteran status, gender identity, sexual orientation or any other category protected by law.

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Join us in our mission to transform healthcare while building a life that works in harmony both in and outside the office.