Utilization Management Nurse

Become a part of our caring community. Are you passionate about helping individuals access the services and support they need to live safely and independently in their communities?

About the role

As a Utilization Management (UM) Nurse, you will play a vital role in improving the health and well-being of Illinois Medicaid members by reviewing and authorizing Long-Term Services and Supports (LTSS) and Home and Community-Based Services (HCBS). You'll combine your clinical expertise, critical thinking, and compassionate approach to evaluate member needs, make evidence-based coverage determinations, and ensure access to appropriate care and services. Working independently while collaborating with providers, members, and interdisciplinary teams, you'll help deliver person-centered, high-quality, and cost-effective healthcare solutions. This position offers the opportunity to make a meaningful impact, navigate complex clinical scenarios, and contribute to an organization dedicated to improving health outcomes and member experiences across Illinois.

Responsibilities

• Use clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures related to Long Term Services and Support authorizations 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.
• Ensure timely and accurate authorization creation and determinations in accordance with Illinois Department of Healthcare and Family Services (HFS), contractual, and regulatory requirements.
• Review clinical information and make coverage determinations for Long-Term Services and Supports (LTSS) and Home and Community-Based Services (HCBS).
• Make decisions related to denials for HCBS-covered services in accordance with applicable state, contractual, and regulatory guidelines.
• Continue to coordinate and communicate with providers, members, and interdisciplinary teams to facilitate optimal care and service delivery.

Requirements

• Licensed Registered Nurse (RN) in Illinois with no disciplinary action or the ability to obtain IL RN licensure prior to start date.
• 1+ years of experience in utilization management/LTSS service authorization.
• 2+ years of clinical experience, preferably in acute care, skilled or rehabilitation clinical setting, or a Medicaid Managed Care Organization.
• Comprehensive knowledge of Microsoft Word, Outlook, and Excel.

Qualifications

• Bachelor's degree in nursing, Health Services, Healthcare Administration, Business Administration, or a related field.
• Previous Medicare/Medicaid experience.
• Previous experience in discharge planning and/or home health, HCBS, rehabilitation, or LTSS programs.

Additional Information

• Location: Must reside in Illinois, Wisconsin, or Indiana.
• Workstyle: This is a remote position supporting members and providers throughout Illinois with periodic in-office attendance required for meetings, training, collaboration, and other business needs.
• Travel: May be required to attend occasional in-state meetings, training sessions, or provider/member events, up to 25% of the time.

To ensure home or hybrid home/office employees’ ability to work effectively, the self-provided internet service must meet the following criteria: at minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable, or DSL connection is suggested. Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.

Schedule

Monday through Friday, 8am to 5pm CST. Scheduled weekly hours: 40.

Pay

The pay range 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, and certifications. Pay range: $71,100 - $97,800 per year. This job is eligible for a bonus incentive plan based upon company and/or individual performance.

Benefits

Humana offers competitive benefits that support whole-person well-being, including:

• 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 and many other opportunities.