National Medicaid Utilization Management, Associate Director

Humana Inc. Rogers , AR 72757

Posted 2 months ago

Description

The 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).

Responsibilities

As Humana's Medicaid membership continues to grow, the National Medicaid Clinical Operations team is expanding our shared services organization to enhance the clinical delivery process. The 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.

Detailed 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 the Centralized Utilization Management Outpatient operations team;

  • 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 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 and delivery of Utilization Management services.

Participate in on-call rotation program to provide after hours, 24/7 clinical coverage requirements.

Required Qualifications

  • Bachelor's Degree in Nursing;

  • 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

Preferred Qualifications

  • Master's Degree in Nursing or Business-related field

Additional Information

This position is open to working remote (with the ability to support and work in Eastern Time Zone)

Scheduled Weekly Hours

40

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
RN Utilization Mgt/Fer Weekend Fri Sat Sun (7A7P)

Humana Inc.

Posted 1 week ago

VIEW JOBS 9/10/2021 12:00:00 AM 2021-12-09T00:00 Description The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Responsibilities The Utilization Management Nurse 2 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. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. Required Qualifications * Licenses RN with no disciplinary action and ability to be licensesd in multiple states * Clinical experience in an acute care, skilled or rehabilitation setting * Experience in utilization management or related activities reviewing criteria to ensure appropriateness of care * Comprehensive knowledge of Microsoft Word, Outlook and Excel and ability to easily navigate through multiple applications * Ability to work independently under general instructions and with a team * 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 * This is a weekend position. Saturday, Sunday, Monday 7a-7p, hours subject to change based on business needs. Preferred Qualifications * BSN * Health Plan experience * Previous Medicare/Medicaid Experience * Call center or triage experience * Bilingual is a plus Additional Information This is a weekend position. Friday, Saturday, Sunday 7a-7p, hours subject to change based on business needs. As part of our hiring process for this opportunity, we will be using an interviewing technology called Montage Text/ Voice Messaging to enhance our hiring and decision-making ability. This 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. If you are selected to move forward, you will receive a text correspondence inviting you to participate in a Text Message screen. You should anticipate this interview to take about 5 to 10 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to the next round of interviews. If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/Buzz and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker. Scheduled Weekly Hours 36 Humana Inc. Rogers AR

National Medicaid Utilization Management, Associate Director

Humana Inc.