Become a part of our caring community and help us put health first
 

The Associate Director, Utilization Management utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Associate Director, Utilization Management Nursing requires a solid understanding of how organization capabilities interrelate across department(s).

Position Responsibilities:

• Serve as a liaison between Humana and the State regarding Prior Authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.
• Coordinates with Clinical Leadership team to ensure all utilization reviews are following the terms of the Contract.
• Responsible for directing the activities and performance of the utilization management staff; direct performance regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, and other clinical and medical management programs.
• Partner with the SIU Team to assure that service guidance to utilization management staff, prior authorization team members ensuring that the service provided meets or exceeds clinical and procedural and Medicaid standards.
• Ensure adoption and consistent application of appropriate medical necessity criteria.
• Monitor, analyze, and implement appropriate interventions based on utilization data, including identifying and correcting over- or under-utilization of services.
• Assure that prior authorization functions and decisions are made in a timely and consistent manner based on clinical criteria and 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 Kentucky Medicaid and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.

Use your skills to make an impact
 

Required Qualifications

• Unrestricted licensed Registered Nurse (RN) or Master's level clinician with independent licensure in the state of Kentucky, holding qualifications such as LCSW (Licensed Clinical Social Worker), LPCC (Licensed Professional Clinical Counselor), or LMFT (Licensed Marriage and Family Therapist).
• 5 years Utilization Management Experience such as Prior Authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.
• 1 year experience working with Medicaid and or Medicare programs
• 2 years of supervisory/management experience with direct reports
• Ability to analyze data to identify trends and opportunities for improvement in the UM program
• Comprehensive knowledge of Microsoft Office applications including Word, Excel, and Outlook.
• Knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards
• Must reside in Kentucky area and report to the office 3 days a week and be available to travel 10% as needed to attend team meetings or other market meetings.

Preferred Qualifications

• BSN, bachelor’s degree in health services, healthcare administration, or business administration
• Bilingual in any language you are fluent in reading and writing in addition to the English language

Additional Information

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 required.
• 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 cal