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The Associate Director, Health Services Nursing is responsible for driving excellence in care management (CM) and utilization management inpatient (UM) clinical operations through process improvement initiatives, process development, market enablement, targeted process audits, and training facilitation. The Associate Director, Health Services Nursing, collaborates across clinical and operational teams to advance best practices, support strategic growth, optimize performance and advance best practices.
The Associate Director, Health Services Nursing, leads all efforts in finding and executing creative ways to remove friction from the system for both our members and provider partners at every opportunity.
Oversee the assessment and evaluation of members' needs and requirements to achieve and maintain optimal wellness by guiding members/families toward and facilitate interaction with resources appropriate for the care and well-being of members.
Coordinates with the Clinical Leadership team to ensure all utilization reviews are in compliance with the terms of the Medicaid contract.
Provide supervision and daily guidance to care management and utilization management team members ensuring that the service provided meets or exceeds clinical and procedural National Committee for Quality Assurance (NCQA) and state standards.
Ensure adoption and consistent application of appropriate medical necessity criteria.
Monitor and evaluate performance metrics and outcomes to ensure the effectiveness and quality of care management activities
Oversee care management and utilization management functions and assure that decisions are made in a timely and consistent manner based on clinical criteria and contract requirements meet timeliness standards to ensure appropriate Notice of Action is followed including collaboration with the Medical Director to ensure reason for denial, reduction, or termination is specific and clear.
Develop and implement departmental policies and procedures in accordance with contract changes and/or updates.
Maintain compliance with NCQA, Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.
Participate in audit preparation and response, including EQRO and other regulatory reviews.
Develop team members and create department process flows.
Lead multiple managers or highly specialized professional associates.
Facilitate cross-departmental collaboration to optimize member outcomes and operational efficiencies.
Decisions are typically related to identifying and resolving complex technical and operational problems within department(s).
Use your skills to make an impact
Required Qualifications
An active, unrestricted Registered Nurse (RN) license in the State of South Carolina with no disciplinary actions.
Bachelor's degree in nursing (BSN) or a related healthcare field.
Three (3) or more yearsof clinical leadership experience in utilization management.
Three (3) or more yearsof care management leadership experience.
Three (3) or more yearsof Medicaid-related experience.
Familiarity with InterQual, MCG, and/or ASAM criteria.
Comprehensive knowledge of Microsoft Office applications, including PowerPoint, Word, Excel, and Outlook.
Knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards.
Preferred Qualifications
South Carolina residency.
Bachelor's degree in nursing (BSN), Public Health, Health Administration, Health Policy, or Business.
Knowledge of Humana's internal policies, procedures, and systems.
Additional Information
Workstyle:This is a remote position.
Travel:Up to 50% to support team engagement and strategic planning initiatives in Humana's Columbia, SC office location.
Direct Reports:Up to 5 associates.
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees92 ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay 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.
$104,000 - $143,000 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
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.
