Utilization Management Nurse

Humana • Indianapolis, IN

3d • $71,100 - $97,800 • Hybrid

About The Position

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.

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

Nice To Haves

• 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.

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.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level