Remote Utilization Management Nurse – LTSS/HCBS Coverage

Humana; Indiana (PA); Hybrid; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana, Inc. seeks a Utilization Management (UM) Nurse to review LTSS/HCBS authorizations for Illinois Medicaid members, applying clinical judgment and policy knowledge.

You will coordinate with providers and members to facilitate appropriate care and ensure timely determinations in line with HFS requirements. This remote role supports Illinois with periodic in-person meetings; IL RN licensure and 1+ year UM LTSS experience are required, plus 2+ years of clinical background.

Qualifications

• RN IL licensure and no disciplinary action.
• 1+ years of Utilization Management/LTSS service authorization.
• 2+ years of clinical experience in acute, skilled, rehab, or Medicaid settings.
• Proficiency with Microsoft Word, Outlook and Excel.

Responsibilities

• Review LTSS and HCBS criteria to authorize services.
• Coordinate with providers and members to facilitate care.
• Make timely coverage determinations following state and contract rules.
• Denial decisions for HCBS services per guidelines.
• Collaborate with interdisciplinary teams to ensure optimal service delivery.

Skills

RN licensure IL

UM/LTSS experience

Clinical background

Education

Bachelor's degree in Nursing or related field

Tools

Microsoft Word

Outlook

Excel

Job description

Humana, Inc. seeks a Utilization Management (UM) Nurse to review LTSS/HCBS authorizations for Illinois Medicaid members, applying clinical judgment and policy knowledge.

You will coordinate with providers and members to facilitate appropriate care and ensure timely determinations in line with HFS requirements. This remote role supports Illinois with periodic in-person meetings; IL RN licensure and 1+ year UM LTSS experience are required, plus 2+ years of clinical background.