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.
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.
- 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/orMilliman (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.
- 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.
- 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.
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
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