Utilization Management LTSS RN

Become a part of our caring community and help us put health first
 

The Utilization Management (UM) Nurse 2 RN uses clinical nursing skills to support the coordination, documentation and communication of long-term support and services and benefit administration determinations. The UM Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The UM Nurse 2 work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. You will report to the Manager Utilization Management Nursing.

In this role you will:

• Use clinical knowledge, communication skills, and independent critical thinking skills towards.
• Interpret criteria and procedures related to Long Term Services and Support authorizations to provide the best treatment, care, or services for members.
• Coordinate and communicate with providers, members, or other parties to facilitate care and treatment.
• Understand department and organizational strategy and operating goals, including their linkages to related areas.
• Follow established guidelines/procedures.
• Oversee LTSS Utilization Management quality performance, including monitoring LTSS UM performance measures and trends in service authorization compliance points and working with Utilization Manager to develop performance improvement initiatives as appropriate.
• Attends and advocates on ICT meetings for State Fair Hearings, report monitoring, and review,
• Attends DMAS training and compliance meetings
• Routine communication with DMAS, as needed
• Ensures compliance with state and federal requirements and NCQA standards

Use your skills to make an impact
 

Required Qualifications

• Active Registered Nurse license in the state of Virginia, or obtain a multi-state license bordering contiguous state that participates in the enhanced licensure, (eNLC) without disciplinary action
• Minimum 3 years previous experience in utilization management/ LTSS service authorization
• Minimum two, (2) years prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting or Medicaid Managed Care Organization
• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment
• Ability to work independently under general instructions and with a team

Preferred Qualifications

• Bachelor's or Associate's Degree in Nursing or related field.
• Telephonic case management or in hospital Case Management experience
• Previous experience in discharge planning and/or home health or rehabilitation
• Previous Medicare/Medicaid Managed care experience

Additional Information:

Workstyle: Remote work at Home

Location: Virginia or reside within 40 miles of one of the following contiguous bordering states - Tennessee, West Virginia, North Carolina, Maryland, or Kentucky.

Schedule: Must work a minimum of 8 hours between 8:00 AM to 5:00 PM Eastern Time

Travel: Less than 25% attend onsite market meetings as business needs. May need to attend onsite meetings in Humana Healthy Horizons office in Glen Allen, VA

Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

Work at Home Guidance: Work at Home Guidance

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is required.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Interview Format

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

 

$71,100 - $97,800 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us
 

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

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Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.