Manager, Utilization Management Nursing
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AI Summary
The Manager, Utilization Management Nursing leads and oversees operations supporting Long-Term Services and Supports (LTSS) members, ensuring timely and accurate authorization determinations. They monitor productivity, quality, and compliance metrics while collaborating with cross-functional teams to improve clinical outcomes.
Become a part of our caring community
The Manager, Utilization Management (UM) Nursing – LTSS utilizes clinical nursing expertise to lead and oversee Utilization Management operations supporting Long-Term Services and Supports (LTSS) members. The Manager, Utilization Management Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Manager, Utilization Management Nursing works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.- Uses clinical knowledge, communication skills, and independent critical thinking skills toward interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for Members
- Ensure timely and accurate authorization creation and determinations in accordance with HFS, contractual, and regulatory requirements.
- Lead and oversee Utilization Management Assistant Supervisors supporting LTSS populations.
- Monitor Electronic Visit Verification (EVV) compliance and utilization trends to support quality and program integrity.
- Monitor productivity, quality, utilization, and turnaround-time metrics.
- Provide leadership and oversight of LTSS Utilization Management operations.
- Provide operational oversight for LTSS covered services, authorization processes, productivity, quality, and compliance.
- Hires, trains, coaches, counsels and evaluates performance of direct reports
- Work collaboratively with UM leadership to assess and mitigate inefficiencies and provide solutions to improve clinical outcomes
- Collects and analyzes data as necessary to drive operational metrics and associate performance
- Collaborate with Care Management, Quality, Medical Directors, and operational partners.
- Makes decisions that are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area
- Facilitates cross departmental collaboration and conduct briefings and area meetings; maintains frequent contact with other managers across functional areas
Use your skills to make an impact
Required Qualifications
- Licensed Registered Nurse in Illinois (IL), with no disciplinary action
- Minimum 3 years of Utilization Management experience, preferably Medicaid Managed Care and/or LTSS including leadership of supervisors or team leads.
- Previous experience in utilization management
- Must be passionate about contributing to an organization focused on continually improving Member experiences
Preferred Qualifications
- BSN, Bachelor's degree in Health Services, Healthcare Administration, or Business Administration
- Prior management experience
- Health Plan experience
- Prior Medicare / Medicaid experience
- Bilingual
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40Pay 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.
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 at Humana.com and at CenterWell.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.
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