Associate Director, Health Services Nursing

Humana • Carolina, SC

10d • Remote

About The Position

The Associate Director, Health Services Nursing is responsible for driving excellence in care management (CM) and utilization management inpatient (UM) clinical operations through process improvement initiatives, process development, market enablement, targeted process audits, and training facilitation. The Associate Director, Health Services Nursing, collaborates across clinical and operational teams to advance best practices, support strategic growth, optimize performance and advance best practices. The Associate Director, Health Services Nursing, leads all efforts in finding and executing creative ways to remove friction from the system for both our members and provider partners at every opportunity. Oversee the assessment and evaluation of members' needs and requirements to achieve and maintain optimal wellness by guiding members/families toward and facilitate interaction with resources appropriate for the care and well-being of members. Coordinates with the Clinical Leadership team to ensure all utilization reviews are in compliance with the terms of the Medicaid contract. Provide supervision and daily guidance to care management and utilization management team members ensuring that the service provided meets or exceeds clinical and procedural National Committee for Quality Assurance (NCQA) and state standards. Ensure adoption and consistent application of appropriate medical necessity criteria. Monitor and evaluate performance metrics and outcomes to ensure the effectiveness and quality of care management activities Oversee care management and utilization management functions and assure that decisions are made in a timely and consistent manner based on clinical criteria and contract requirements 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 NCQA, Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements. Participate in audit preparation and response, including EQRO and other regulatory reviews. Develop team members and create department process flows. Lead multiple managers or highly specialized professional associates. Facilitate cross-departmental collaboration to optimize member outcomes and operational efficiencies. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s).

Requirements

• An active, unrestricted Registered Nurse (RN) license in the State of South Carolina with no disciplinary actions.
• Bachelor's degree in nursing (BSN) or a related healthcare field.
• Three (3) or more years of clinical leadership experience in utilization management.
• Three (3) or more years of care management leadership experience.
• Three (3) or more years of Medicaid-related experience.
• Familiarity with InterQual, MCG, and/or ASAM criteria.
• Comprehensive knowledge of Microsoft Office applications, including PowerPoint, Word, Excel, and Outlook.
• Knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards.

Nice To Haves

• South Carolina residency.
• Bachelor's degree in nursing (BSN), Public Health, Health Administration, Health Policy, or Business.
• Knowledge of Humana's internal policies, procedures, and systems.

Responsibilities

• Driving excellence in care management (CM) and utilization management inpatient (UM) clinical operations through process improvement initiatives, process development, market enablement, targeted process audits, and training facilitation.
• Collaborating across clinical and operational teams to advance best practices, support strategic growth, optimize performance and advance best practices.
• Leading efforts in finding and executing creative ways to remove friction from the system for both members and provider partners.
• Overseeing the assessment and evaluation of members' needs and requirements to achieve and maintain optimal wellness by guiding members/families toward and facilitating interaction with resources appropriate for the care and well-being of members.
• Coordinating with the Clinical Leadership team to ensure all utilization reviews are in compliance with the terms of the Medicaid contract.
• Providing supervision and daily guidance to care management and utilization management team members ensuring that the service provided meets or exceeds clinical and procedural National Committee for Quality Assurance (NCQA) and state standards.
• Ensuring adoption and consistent application of appropriate medical necessity criteria.
• Monitoring and evaluating performance metrics and outcomes to ensure the effectiveness and quality of care management activities.
• Overseeing care management and utilization management functions and assuring that decisions are made in a timely and consistent manner based on clinical criteria and contract requirements 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.
• Developing and implementing departmental policies and procedures in accordance with contract changes and/or updates.
• Maintaining compliance with NCQA, Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.
• Participating in audit preparation and response, including EQRO and other regulatory reviews.
• Developing team members and creating department process flows.
• Leading multiple managers or highly specialized professional associates.
• Facilitating cross-departmental collaboration to optimize member outcomes and operational efficiencies.

Benefits

• medical
• dental
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Director