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. You will 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. You will support quality efforts both at the market and enterprise level, so achieve quality targets in HEDIS, STARS, and NCQA accreditation. The Utilization Management Nurse Lead advises executives to develop functional strategies (often segment specific) on matters of significance. They exercise independent judgment and decision making on complex issues regarding job responsibilities and related tasks, and work under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action.

• 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 Centers for Medicare & Medicaid Services (CMS) regulations as well as Michigan Dual Special Needs Plan (DSNP) Contract terms.
• Work in conjunction with the Quality Improvement Director to develop quantifiable metrics that can track and evaluate the results of the 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 the Michigan Department of Health and Human Services (MDHHS) standards.
• Work in conjunction 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 rule and regulations.
• In conjunction with Humana's UM monitoring and oversight processes, monitors and analyzes Michigan DSNP specific outcomes. The analysis initiates action to implement appropriate interventions based on utilization data. This includes identifying and correcting over- or under-utilization of services, addressing issues with timeliness standards, ensuring appropriate Notice of Action is followed, and collaborating with Medical Directors. The collaboration ensures that the reason for denial, reduction, or termination is specific and clear.
• 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, National Committee for Quality Assurance (NCQA), Department of Health and Human Services (DHHS), CMS guidelines and contractual requirements.

Required 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 or associate 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 National Committee for Quality Assurance (NCQA) standards.

Preferred Qualifications

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

Additional Information

• Workstyle: This is a remote position.
• Travel: Up to 25% travel to Michigan Department of Health and Human Services (MDHSS), locations across Michigan, including participation in team engagement meetings and conferences both within and outside the state.
• Direct Reports: None at hire; potential to increase to five (5) associates post market expansion.

WAH Internet Statement 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.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Interview Format As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. Work at Home RequirementsTo 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 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. $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 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.