[Hiring] Utilization Management Nurse Lead @Humana

Role Description

The Utilization Management Nurse Lead uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting data, criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.

• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Accountable, in partnership with the Chief Medical Officer (CMO), to analyze utilization management (UM) trends and drivers impacting member outcomes and financial impact.
• Support quality efforts both at the market and enterprise level to achieve quality targets in HEDIS, STARS, and NCQA accreditation.
• Advise executives to develop functional strategies on matters of significance.
• Exercise independent judgment and decision making on complex issues regarding job responsibilities and related tasks.
• Serve as a liaison between Humana UM operations and the State of Michigan regarding prior authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.
• Coordinate with Humana’s Clinical Leadership teams to ensure utilization reviews comply with CMS regulations as well as Michigan Dual Special Needs Plan (DSNP) Contract terms.
• Work with the Quality Improvement Director to develop quantifiable metrics that can track and evaluate the results of targeted interventions designed to reduce health disparities and address health inequities.
• Manage Michigan state reporting and collaborate with the UM operations teams to aggregate and analyze data and reporting metrics.
• Provide quality support to the supervision and daily guidance of prior authorization associates ensuring outcomes that meet or exceed Humana and MDHHS standards.
• Work with Humana’s Medicare UM Committees to ensure adoption and consistent application of appropriate medical necessity criteria.
• Participate in oversight of the programs to ensure that Enrollees are accessing and utilizing services in an appropriate manner in accordance with all applicable rules and regulations.
• Monitor and analyze Michigan DSNP specific outcomes, initiating action to implement appropriate interventions based on utilization data.
• Ensure development and implementation of departmental policies and procedures in accordance with contract changes or updates.
• Provide oversight to ensure Humana maintains compliance with MDHHS, NCQA, DHHS, CMS guidelines and contractual requirements.

Qualifications

• Must reside in or be willing to relocate to the state of Michigan.
• An active, unrestricted registered nurse (RN) license in the state of Michigan.
• Bachelor’s degree in nursing, health services, healthcare administration, business administration or a related field.
• Minimum five (5) years of clinical experience in utilization management.
• Minimum two (2) years of formal or informal leadership experience.
• Comprehensive knowledge of Microsoft Office applications including PowerPoint and Excel.
• Knowledge of Medicare regulatory requirements and NCQA standards.

Requirements

• Master’s degree in nursing, health services, healthcare administration, business administration or a related field (preferred).
• Knowledge of Medicaid regulatory requirements (preferred).
• Experience with contracting, audit, risk management, or compliance (preferred).
• Proficiency in Power BI or comparable analytical tools (preferred).
• Experience in NCQA UM measures (preferred).

Benefits

• Medical, dental and vision benefits.
• 401(k) retirement savings plan.
• Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance and many other opportunities.

Company Description

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.