Utilization Management LTSS Registered Nurse

Virginia, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess an active Registered Nurse license in Virginia or a multi-state license in a contiguous eNLC participating state without disciplinary action. A minimum of 1 year of utilization management experience and 2 years of clinical experience, preferably in an acute care, skilled, or rehabilitation setting, are required. Intermediate to advanced proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) and the ability to navigate multiple systems and troubleshoot technical issues in a remote environment are also necessary. Preferred qualifications include experience with LTSS service authorization, waiver experience, Medicare/Medicaid, discharge planning, and home health or rehabilitation. Bilingual skills are a plus. Applicants must have a reliable internet connection with at least 25 Mbps download and 10 Mbps upload speeds and a dedicated workspace free from interruptions.

Responsibilities

The Utilization Management Nurse will utilize clinical nursing skills to support the coordination, documentation, and communication of Long-Term Supports and Services (LTSS) and/or benefit administration determinations. This role involves interpreting criteria, policies, and procedures related to LTSS authorizations to ensure members receive appropriate treatment and services. Responsibilities include coordinating and communicating with providers, members, and other parties to facilitate optimal care and understanding department and organizational strategy. The nurse will make independent decisions regarding their work methods, often in ambiguous situations, requiring minimal direction.

Skills

Utilization Management

Long-Term Services and Supports (LTSS)

Registered Nurse (RN)

Clinical Nursing

Acute Care

Skilled Nursing

Rehabilitation

Microsoft Office Suite (Word, Excel, PowerPoint)

Technical Troubleshooting

Critical Thinking

Communication

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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