IL Medicare/Medicaid LTSS Utilization Management Nurse - Schaumburg IL

Profile

Description

The Utilization Management Nurse uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Responsibilities

The Utilization Management (UM) Nurse utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations.

The UM Nurse manages assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Illinois Medicare Medicaid Alignment Initiative (MMAI) Long Term Services and Support (LTSS) program offers person-centered care planning, service coordination and support services for members receiving Long-Term care (LTC) and Home and Community Based Services (HCBS).

The UM Nurse is responsible for reviewing, interpreting, and determining appropriate hours of service based on need and working with Care Coordinators and the IL Medical Director to ensure members needs are met and there is proper justification when approved services exceed maximums.

This role is the UM Nurse collaborating with the care coordination team who facilitates, promotes and advocates for the member's ongoing self-sufficiency and independence.

This role will support the Training for care coordination staff and member file reviews for compliance

Member populations and Waivers served by this program include:

Elderly Waiver

Brain Injury Waiver

Physically Disabled Waiver

HIV/AIDS Waiver

Supported Living Facility Waiver

Aged Blind and Disabled (ABD)

Serious Mental Illness

Long Term Care

Required Qualifications

Bachelor's degree

5 years of varied clinical experience preferably in an acute care skilled or rehabilitation clinical setting

Current unrestricted Licensed Registered Nurse (RN) in IL with no disciplinary action

1 year Utilization Management Experience

Comprehensive knowledge of Microsoft Word, Outlook, Excel and other programs

Ability to work independently under general instructions and in a team environment

Ability to manage multiple priorities in a fast paced environment

This role will report to the Schaumburg, IL Office (see additional information below)

Must be available to work Monday - Friday 8:00 AM - 5:00 PM with occasional flexibility due to business needs

Work At Home requirements

Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work.

Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required

Preferred Qualifications

3-5 years of Critical Care Nursing Experience

Health Plan or Managed Care Experience

Experience working with Medicaid and Medicare Medicaid population.

Experience working with long-term services and support

Additional Information

In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves. The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process.

Location for this position will be in Schaumburg, IL.

#ILMEDICAID

Interview Process

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes. Be sure to check your Junk/Spam folder so you do not miss the emails.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com