Remote Utilization Management RN (Illinois Medicaid)


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Location: IL
Location Type: Remote
Schedule: Full_time
Req: R-327293

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

Humana Gold Plus-Integrated is seeking a Utilization Management (UM) Nurse who utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse uses clinical knowledge, communication skills, and independent critical thinking skills for interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for members.


The UM Nurse roles and responsibilities:

·       Coordinates and communicates with providers, members, physicians, or other parties to facilitate optimal care and treatment.

·       Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

·       Reviews and applies preferred criteria to acute inpatient, skilled nursing facility, acute rehab, and Long-Term Acute Care Hospital (LTACH) cases.

·       Communicates with Medical Directors regarding denied cases.

·       Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

·       Follows established guidelines/procedures.

Use your skills to make an impact

Required Qualifications

  • Unrestricted Licensed Registered Nurse (RN) in the State of Illinois with no disciplinary action.
  • 3+ years of Medical Surgical, Critical Care, ER experience, or experience in a skilled/rehabilitation clinical setting.
  • 2+ years of previous experience in Utilization Management.
  • 2+ years of previous experience in MCG.
  • Comprehensive knowledge of Microsoft Word, Outlook, and Excel.
  • Must be available to work the following times/hours: Monday-Friday, shifts will be either 8am-5:00pm CST with 1 hour lunch break or 9:00am-5:30pm CST with 1/2-hour lunch break. (Hours will be CST regardless of where you reside)
  • Rotating weekend requirements: on call for expedited requests or overflow when a decision must be made to comply with regulatory timeframes before the regular work week hours. Additionally, this role requires a minimum of 1 summer and 1 winter holiday/holiday weekend coverage rotation. Hours are determined by work volume.

Work at Home Requirements

  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
  • Satellite, cellular and microwave connection can be used only if approved by leadership.
  • Humana will provide Home or Hybrid Home/Office associates 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.

Preferred Qualifications

  • BSN or bachelor’s degree in a related field.
  • Ability to use a variety of electronic information applications/software programs including electronic medical records (EMR).
  • Health Plan experience.
  • Previous Medicare-Medicaid Alignment Initiative (MMAI)/Medicare/Medicaid experience.
  • Familiarity with Medicare, Medicaid, and NCQA regulations, such as turn-around times.
  • Call center or triage experience.
  • Bilingual is a plus.

Additional Information

Workstyle/Travel: Remote

Work Schedule:  Hours for this role are Monday-Friday, shifts will be either 8am-5:00pm CST with 1 hour lunch break or 9:00am-5:30pm CST with 1/2-hour lunch break. (Hours will be CST regardless of where you reside)

Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more…..


Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Montage, 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.

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



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.


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 because he or she is a protected veteran. It is also the policy of  Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.