Remote RN: Utilization Management for LTSS/HCBS

Humana Inc; Northern (KY); Hybrid; USD 71,000 - 98,000; Full time

Job summary

Humana Inc. is seeking a Utilization Management Nurse to review and authorize LTSS and HCBS for Illinois Medicaid members.

You will evaluate clinical information, make evidence-based coverage determinations, and coordinate with providers and interdisciplinary teams to ensure access to appropriate care and services. The role requires an IL RN license (or eligibility), 1+ year UM/LTSS experience, and 2+ years clinical background in relevant settings.

Qualifications

• Valid IL RN license or ability to obtain IL licensure prior to start date.
• 1+ year in utilization management/LTSS authorizations.
• 2+ years clinical experience (acute care, skilled or rehab, or Medicaid MCO).
• Proficiency with Microsoft Word, Outlook and Excel.

Responsibilities

• Review LTSS/HCBS requests and make coverage determinations.
• Coordinate with providers, members, and interdisciplinary teams to facilitate care.
• Ensure timely and accurate authorization creation and determinations in accordance with Illinois Department of Healthcare and Family Services (HFS) rules.
• Communicate denials consistent with contractual and regulatory guidelines.

Skills

RN IL licensure

Utilization management

Clinical experience

Education

Bachelor's degree in nursing

Tools

Microsoft Word

Outlook

Excel

Job description

Humana Inc. is seeking a Utilization Management Nurse to review and authorize LTSS and HCBS for Illinois Medicaid members.

You will evaluate clinical information, make evidence-based coverage determinations, and coordinate with providers and interdisciplinary teams to ensure access to appropriate care and services. The role requires an IL RN license (or eligibility), 1+ year UM/LTSS experience, and 2+ years clinical background in relevant settings.