Utilization Management Nurse

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.

Responsibilities

• Use clinical knowledge, communication skills, and independent critical thinking to interpret 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

Preferred qualifications include:

• 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.
• Work at Home Requirements: To ensure effective work, self-provided internet service must meet the following criteria: at minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps; 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 is $71,100 - $97,800 per year. This job is eligible for a bonus incentive plan based on 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.