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.

• 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.
• Attend and advocate on ICT meetings for State Fair Hearings, report monitoring, and review.
• Attend DMAS training and compliance meetings.
• Routine communication with DMAS, as needed.
• Ensure compliance with state and federal requirements and NCQA standards.

• 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.

• 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.

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.

• 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…