Remote Prior Authorization Rn Jobs in Rockford, IL

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The Manager, Care Management leads teams of nurses, social workers, behavioral health professionals, and care management support professionals responsible for the care management of Medicaid members in Humana's Illinois market. The Manager, Care Management follows guidelines and departmental procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.

Position Responsibilities:

The Manager, Care Management oversees the assessment and evaluation of members' needs and requirements to achieve and maintain optimal wellness by guiding members and families toward and facilitate interaction with resources appropriate for the care and wellbeing of members.

Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving the Care Management department.

• Support and enhance a care management model that leverages extenders (e.g., CHWs, peer support specialists, housing advocates) to address social determinants of health for Medicare-eligible adults.
• Promote culturally responsive, trauma-informed, and person-centered approaches across all care management activities.
• Foster partnerships and collaboration between Care Management and community-based organizations, aging services, housing providers, and public agencies.
• Monitor program performance and use data to evaluate impact, identify gaps, and drive continuous improvement.
• Align departmental processes and performance with market and enterprise objectives to control cost and improve operational efficiencies for existing product lines
• Collaborate with internal teams and external partners to ensure seamless integration of non-clinical support associates into care planning and service delivery. assist in coordinating effort between support departments within the organization.
• Assure departmental compliance with applicable federal, state, and contractual requirements and standards.
• Create a productive and positive department through written and verbal communication, briefings and team meetings, and collaboration with other Care Management leadership.
• Develop and maintain policies and procedures that support consistent, high-quality service delivery across the system of care and contribute to the organization's mission of advancing health equity and reducing disparities.
• Support training and capacity-building efforts for care management extenders, including CHWs and peer specialists.
• Assist in resolving individual member issues related to housing, food insecurity, transportation, and other social needs.
• Represent the care management program in collaborative initiatives, advisory groups, and community forums.
• Participate as a member of the management team in promoting Humana's mission for strategic growth and development.
• Fully participate in Humana's Compliance Program, including compliance with Humana's Code of Conduct, policies and procedures, and all applicable Privacy and Security laws.
• Coordinate needed support to operations areas through smooth workflows and cost efficient, quality product delivery.
• Continuously improve customer satisfaction through effective program monitoring to achieve timely and appropriate service delivery and reduced member problems.
  

Upon hire, this role will be assigned to support either MLTSS or LTSS based on business needs.

Use your skills to make an impact

Required Qualifications

• Must reside in Illinois
• Minimum of an Associate's Degree
• Active Registered Nurse (RN) license or Social Work (SW) license
• 5+ years of professional experience
• 2+ years of management or supervisory experience.
• Proficiency in analyzing and interpreting data trends.
• Progressive operational leadership experience
• Strong, demonstrated communication, analytical, problem solving and team playing skills.
• Knowledge of Medicaid/Medicare, and long-term care guidelines, benefits and policies and procedures.
• Demonstrated computer skills in Microsoft Windows, Outlook, Excel, Word as well as other MIS software applications.
• Strong understanding of care management models and the role of extenders in addressing social needs
• Demonstrated ability to lead cross-functional initiatives and collaborate with external partners
• Ability to operate independently and in a team environment.

Preferred Qualifications

• Bachelor's degree or advanced degree in nursing or business health field
• Previous experience working in a managed care field
• 5 or more years of previous management/supervisor level experience
• Experience managing or collaborating with community health workers, peer support specialists, or housing programs
• Familiarity with Illinois Medicaid policies and systems

Additional Information

• Workstyle: This is a remote position that requires travel.
• Travel: 50 - 75% field-based interactions conducting care team oversight visits, meeting with members and/or their families, community partners and other care teams. May need to attend occasional onsite meetings in Humana's Illinois locations.
• Mileage Reimbursement for Travel: Mileage reimbursement is provided for work-related travel. Eligible mileage includes travel from your home to your first work location, travel between client or assignment locations during the workday, and travel from your final work location back to your home.
• Typical Workdays and Hours: Monday - Friday 8:00 AM - 5:00 PM CST. May need to be provide flexibility with work schedule based on business needs.
• Direct Reports: Up to 15 associates.
• 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.

WAH Internet Statement

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:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• 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 information.

Interview Format

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance.Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

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: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

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. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$86,300 - $118,700 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

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 us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.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. Learn more about what we offer atHumana.comand atCenterWell.com.

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 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.