Utilization Management RN - Payer Operations

Solving Prior Authorization on Both Sides of the Fax Machine: Humata is revolutionizing Prior Authorization and Utilization Management with cutting-edge AI and automation. Our commitment is to deliver a seamless, efficient, and automated workflow for healthcare providers and payers. At Humata, we transcend traditional automation, addressing the complexities of prior authorizations with a powerful blend of AI, automation, and unparalleled payer connectivity. This transformative approach revolutionizes the entire end-to-end experience, setting a new standard for the prior authorization and utilization management process. Humata's mission for providers and payers is to make 90% of PA touchless, enable processing to be completed in <2 minutes when human intervention is required, and bring complete transparency for patients throughout the process.

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

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.