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

The Manager, Utilization Management Nursing uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for members.

The Manager is responsible for ensuring high quality, cost-effective, and appropriate allocation of member services, treatments, and resources. The Manager serves as a resource to Humana’s management team, members, and outside medical providers and vendors.

• Effectively manages attendance, schedules, assignments, and compliance expectations to ensure adequate coverage during traditional and nontraditional business hours (weekend, evenings, and holidays as applicable) to support the needs of the business
• Provides oversight, education, support, and coaching to ensure associates' performance meets expectations and regional operational goals/metrics
• Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions
• Support the daily management and operations of the department.  Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services.
• Implements and executes policies and processes necessary to support the business need and maintain compliance with regulatory requirements
• Analyzes operational and analytical reports to monitor and track operational efficiency
• Ability to perform case reviews.  Properly documents utilization management activities and rationale for all decisions in electronic medical records systems
• Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management
• Additional duties as assigned

Use your skills to make an impact
 

Required Qualifications

• Licensed Registered Nurse (RN) in the states of TN, AL, LA, MS, VA or a compact license, with no disciplinary action
• Clinical experience in a skilled or rehabilitation clinical setting is required for this role
• Utilization Management experience is required for this role
• Strong attention to detail, excellent time management and organizational skills
• Excellent communication skills both verbal and written
• Proficient with Microsoft Word, Outlook and Excel
• Ability to work independently under general instructions and with a team
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Bachelor’s degree in nursing (BSN)
• Prior supervisory or leadership experience is highly preferred
• Experience in a team lead/SME or trainer/preceptor role
• Health Plan experience
• Previous Medicare experience a plus
• MCG experience preferred
• Bilingual is a plus

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates 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 associates 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

Additional Information

• Hours are: Monday-Friday 8am-5pm or 9am-6pm, this role also requires an on-call rotation schedule including after normal business hours and weekends
• 10%-15% of travel may be required in the future based on business needs
• This role will have 12-14 direct reports

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, c