Utilization Management Nurse

Jobtailor; Illinois; On-site; USD 75,000 - 95,000; Full time

Job summary

Jobtailor is seeking a licensed RN in Illinois to review and authorize LTSS and HCBS services, using clinical criteria to guide determinations.

The role requires 1+ year in utilization management and 2+ years clinical experience, with strong MS Word/Outlook/Excel skills, and a commitment to protecting member PHI. Residency in Illinois is required.

Ideal candidates have Medicare/Medicaid exposure and knowledge of Illinois HFS regulations, with ability to collaborate across interdisciplinary teams.

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.
• Comprehensive knowledge of Microsoft Word, Outlook, and Excel.
• Must reside in Illinois.
• Minimum internet speed of 25 Mbps download and 10 Mbps upload.
• Dedicated work space without ongoing interruptions to protect member PHI/HIPAA information.
• Preferred: Bachelor's degree in nursing, Health Services, Healthcare Administration, Business Administration, or a related field.
• Preferred: Previous Medicare/Medicaid experience.
• Preferred: Experience in discharge planning and/or home health, HCBS, rehabilitation, or LTSS programs.

Responsibilities

• Review and authorize Long-Term Services and Supports (LTSS) and Home and Community-Based Services (HCBS).
• Evaluate member needs using clinical expertise and evidence-based criteria.
• Interpret criteria, policies, and procedures related to LTSS authorizations.
• Make coverage determinations and decisions related to denials for HCBS-covered services.
• Coordinate and communicate with providers, members, and interdisciplinary teams.
• Create timely and accurate authorizations and determinations.
• Ensure compliance with Illinois HFS, contractual, and regulatory requirements.
• Facilitate optimal care, treatment, and service delivery.
• Support Illinois Medicaid members and providers.

Skills

LTSS Authorization

HCBS Coverage Determination

Clinical Evaluation

Evidence-Based Criteria Interpretation

Regulatory Compliance

Education

Bachelor's degree in Nursing or related field

Tools

Microsoft Word

Microsoft Outlook

Microsoft Excel

Job description

• Review and authorize Long-Term Services and Supports (LTSS) and Home and Community-Based Services (HCBS)
• Evaluate member needs using clinical expertise and evidence-based criteria
• Interpret criteria, policies, and procedures related to LTSS authorizations
• Make coverage determinations and decisions related to denials for HCBS-covered services
• Coordinate and communicate with providers, members, and interdisciplinary teams
• Create timely and accurate authorizations and determinations
• Ensure compliance with Illinois HFS, contractual, and regulatory requirements
• Facilitate optimal care, treatment, and service delivery
• Support Illinois Medicaid members and providers

Requirements

• 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
• Comprehensive knowledge of Microsoft Word, Outlook, and Excel
• Must reside in Illinois
• Minimum internet speed of 25 Mbps download and 10 Mbps upload
• Dedicated work space without ongoing interruptions to protect member PHI/HIPAA information
• Preferred: Bachelor's degree in nursing, Health Services, Healthcare Administration, Business Administration, or a related field
• Preferred: Previous Medicare/Medicaid experience
• Preferred: Experience in discharge planning and/or home health, HCBS, rehabilitation, or LTSS programs

Core Competencies

Demonstrates expertise in Long-Term Services and Supports (LTSS) and Home and Community-Based Services (HCBS) authorizations, with a strong focus on compliance with Illinois HFS regulations and effective communication with interdisciplinary teams. Proficient in clinical evaluation and decision-making to facilitate optimal care for Illinois Medicaid members.

Highest-signal resume keywords

• Licensed Registered Nurse (RN)
• Utilization Management
• Clinical Experience
• Microsoft Office Suite
• Medicare/Medicaid Experience

ATS Optimization Keywords

Hard Skills

• LTSS Authorization
• HCBS Coverage Determination
• Clinical Evaluation
• Evidence-Based Criteria Interpretation
• Compliance with Regulatory Requirements

Soft Skills

• Communication
• Coordination
• Interpersonal Skills

Certifications & Qualifications

• Registered Nurse (RN) License in Illinois

Industry Keywords

• Illinois HFS
• Medicaid
• Home Health
• Discharge Planning
• Rehabilitation

Tools & Technologies

• Microsoft Word
• Microsoft Outlook
• Microsoft Excel