Description
Humana Healthy Horizons in Louisiana is seeking a Manager, Utilization Management Nursing who will utilize clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Manager, Utilization Management Nursing applies a Person-Centered approach, works within specific guidelines and procedures; applies advanced technical knowledge and clinical criteria to solve moderately complex problems; receives assignments in the form of team and/or department goals and objectives and determines approach, resources, schedules and monitors success of appropriate team or department goals.
Responsibilities
Essential Functions and Responsibilities
- Supervise utilization management personnel and oversee all utilization management functions, including inpatient admissions, concurrent review, prior authorization and referrals to care management.
- Oversee, monitor, orient and train staff in the use of standard utilization management criteria including MCG, Interqual, and ASAM.
- Lead development of utilization management policies and procedures to ensure compliance with state and federal requirements and incorporate industry best practices.
- Collaborate with internal departments, providers, and community partners to support the delivery of high-quality utilization management services, including introducing innovative approaches to utilization management.
- Monitor and maintain staffing levels to meet care and service quality objectives.
- Conduct timely evaluations of direct reports and provide regular opportunities for professional development.
- Influence and assist corporate leadership in strategic planning to improve effectiveness of utilization management programs.
- Collect and analyze performance reports on utilization management functions to monitor adherence with benchmarks, identify opportunities for process improvement, and develop recommendations to leadership.
- Conducts briefings and area meetings; maintains frequent contact with other managers across the department and the company.
Required Qualifications
- Licensed Registered Nurse (RN) in the state of Louisiana with no disciplinary action.
- Must reside in the state of Louisiana.
- Previous experience in utilization management.
- Two (2) or more years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting.
- Two (2) years of leadership experience.
- Knowledge of Interqual, ASAM and/or Milliman (MCG) criteria.
- Comprehensive knowledge of Microsoft Office applications including Word, Excel, and Outlook.
- Ability to work independently under general instructions and with a team.
- Must have the ability to provide a high speed DSL or cable modem for a home office.
- A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
- Satellite and Wireless Internet service is NOT allowed for this role.
- A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
- Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
Preferred Qualifications.
- BSN, Bachelor’s degree in health services, healthcare administration, or related field.
- Experience working with Medicaid and/or health plan Utilization Management.
- Possess subject matter expertise in review of inpatient admission and concurrent reviews requests.
- Experience managing staff who review and process prior authorization, inpatient admission reviews and concurrent reviews.
- Experience serving Medicaid, TANF, and/or CHIP populations.
Additional Information.
- Workstyle: Remote with limited travel.
- Travel: Up to 10% to Humana Healthy Horizons locations in Metairie or Baton Rouge, LA
- Typical Work Days/Hours: Monday – Friday; 8:00am – 5:00pm CST with potential rotating on-call schedule.
- Direct Reports : up to 12 Associates.
Interview Format
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
40
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our [ Link removed ] – Click here to apply to RN, Manager, Utilization Management Nursing (Louisiana Medicaid)
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