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DescriptionThe Associate Director, Utilization Management Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Associate Director, Utilization Management Nursing requires a solid understanding of how organization capabilities interrelate across department(s).ResponsibilitiesAs Humana Healthy Horizons Medicaid membership continues to grow, the National Medicaid Clinical Operations team is expanding our shared services organization to enhance the clinical delivery process. The Nationwide Associate Director, Utilization Management Nursing uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s), and could lead multiple managers or highly specialized professional associates.Responsibilities include:Leads National Medicaid Utilization Management process and teams responsible for supporting Medicaid Market Clinical Operations delivery including:Developing and implementing Clinical Prior Authorization policies, processes, detailed workflows, and leading Centralized Utilization Management Outpatient operations team(s).
Hiring and directly leading a team of Utilization Management nurses and support staff responsible for reviewing and processing clinical authorizations and clinical claims reviews.
Working closely with Medicaid market Utilization Management leaders to collaboratively design processes for market staff to manage full spectrum of Utilization Management authorizations.
Working with Market Medical Directors and vendors to develop processes for routing cases for medical necessity decisions.
Develop IT business requirement, rule development, and training content for administering utilization management process in Humana's clinical systems.
Collaboratively develop Utilization Management and Clinical Claims Review reporting requirements to assure operational oversight and address state reporting requirements for supporting all Medicaid states.
Implementing operational support tools and identifying operational best practices and process opportunities.
Assure compliance with state timeframes for turnaround times on authorization requests, clinical claims reviews and delivery of Utilization Management services.
Oversight and participation of the on-call rotation program to provide after hours, 24/7 clinical coverage requirements.
Required QualificationsBachelor's Degree.
Active RN license, without restrictions or disciplinary action; Compact required within 60 days of hire.
7+ years of Utilization Management nursing experience.
5+ years of Managed Care experience.
5+ years of Utilization Management operational leadership experience.
2+ years of Medicaid experience.
2+ years developing collaborative partnerships with enterprise cross-functional teams.
Recent working knowledge and familiarity with MCG medical criteria and administering clinical practice guidelines.
Ability to lead large scale projects, across cross-functional enterprise teams.
Demonstrated experience and recommendations from peers as a customer-focused, team player, with collaborative approach to leading.
Ability to participate in on-call rotation program to provide after hours, 24/7 clinical coverage requirements.
Must have a room in your home designated as a home office; away from high traffic areas where confidential information may be secured.
Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.
For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to: Provide proof of full vaccination OR Commit to weekly testing, following all CDC protocols, OR Provide documentation for a medical or religious exemption consideration. This policy will not supersede state or local laws. Requests for these exemptions should be submitted at least 2 weeks prior to your scheduled first day of work.
Preferred QualificationsBachelor's or Master's Degree in Nursing or Business-related field.
Experience in the clinical claims review process.
Additional InformationWork Hours: Eastern Time Zone.
Travel: 5-10%
Direct Reports: Up to 5.
Interview FormatAs part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, 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 or computer 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 Hours40
Full-time