Remote RN: Utilization Management for LTSS/HCBS

Humana; Illinois; Hybrid; USD 71,000 - 98,000; Full time

Job summary

Humana is seeking a remote Utilization Management (UM) Nurse to support Illinois Medicaid members by reviewing LTSS and HCBS authorizations, ensuring compliant and timely determinations. The role emphasizes collaboration with providers, members, and interdisciplinary teams to coordinate care, make coverage decisions, and support high-quality member outcomes across Illinois.

Requires IL RN licensure, UM/LTSS experience, clinical background, and proficiency with Word/Outlook/Excel.

Qualifications

• Licensed Registered Nurse (RN) in Illinois with no disciplinary action or able 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 settings or Medicaid MCO.
• Proficient in Microsoft Word, Outlook and Excel.

Responsibilities

• Review LTSS/HCBS criteria and make coverage determinations.
• Coordinate and communicate with providers, members, and other parties to facilitate care.
• Ensure timely authorization creation and determinations in line with requirements.
• Review clinical information to determine LTSS/HCBS coverage.
• Make denials for HCBS-covered services per guidelines.
• Collaborate with providers, members, and interdisciplinary teams to optimize service delivery.

Skills

RN (Illinois licensure)

Utilization management LTSS

Clinical experience

MS Word/Outlook/Excel

Education

Bachelor's degree in Nursing

Medicare/Medicaid knowledge (preferred)

Tools

Microsoft Word

Outlook

Excel

Job description

Humana is seeking a remote Utilization Management (UM) Nurse to support Illinois Medicaid members by reviewing LTSS and HCBS authorizations, ensuring compliant and timely determinations. The role emphasizes collaboration with providers, members, and interdisciplinary teams to coordinate care, make coverage decisions, and support high-quality member outcomes across Illinois.

Requires IL RN licensure, UM/LTSS experience, clinical background, and proficiency with Word/Outlook/Excel.