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