RN Care Management(Remote)

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The Utilization Management Nurse, National Medicaid Clinical Operations is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for inpatient services. This role ensures that all requests meet medical necessity criteria and comply with health plan policies and regulatory requirements. The RN Review Nurse works closely with healthcare providers, interdisciplinary teams, and nonclinical staff to facilitate timely and appropriate care for members. This role will report directly to the Manager, Utilization Management.
Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility

• Communicate with healthcare providers to obtain necessary clinical information and clarify requests
• Coordinate with medical directors and interdisciplinary teams to support decision-making
• Document all review findings and decisions in clinical documentation systems
• Ensure timely and accurate documentation of prior authorization determinations
• Support reporting initiatives and provide data for performance improvement projects

Quality Assurance:

• Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions
• Identify process improvement opportunities and contribute to performance improvement projects

Education and Training:

• Educate providers and staff on prior authorization policies, criteria, and review processes
• Stay current with clinical best practices and regulatory changes

We are seeking a typical Monday-Friday schedule as well as weekend coverage (i.e. Licensed Registered Nurse in Illinois, with no disciplinary action (or willing to obtain Illinois licensure upon hire)
3+ years of clinical nursing experience
Experience with Medicaid policies and procedures
Proficiency in healthcare software and electronic medical records (EMR) systems
Previous experience in utilization management
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Bachelor’s degree
Certification in Case Management (CCM) or Utilization Review (UR)
Experience with Medicaid and Medicare policies and procedures
Knowledge of payer policies, insurance companies and government health programs
Work at Home Requirements: 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: wireless, wired cable or DSL connection is suggested. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
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. This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Humana: Humana Inc. (S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. 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.