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
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
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees' 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 Hours40
Pay RangeThe 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.
$94,900 - $130,500 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of BenefitsHumana, 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.
