Utilization Management Nurse

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 #J-18808-Ljbffr