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? 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. 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. Use your skills to make an impact Required Qualifications Licensed Registered Nurse (RN) in Illinois with no disciplinary action. 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 Preferred 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. 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. Schedule: Monday through Friday, 8am to 5pm CST. Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below 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, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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. About us About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. ​ Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.