Utilization Management Nurse Lead

Humana • Chittenden, VT

20h • $94,900 - $130,500 • Remote

About The Position

The Utilization Management Nurse Lead uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting data, criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. You will coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. Accountable, in partnership with the Chief Medical Officer (CMO), to analyze utilization management (UM) trends and drivers impacting member outcomes and financial impact. You will support quality efforts both at the market and enterprise level, so achieve quality targets in HEDIS, STARS, and NCQA accreditation. The Utilization Management Nurse Lead advises executives to develop functional strategies (often segment specific) on matters of significance. They exercise independent judgment and decision-making on complex issues regarding job responsibilities and related tasks, and work under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action. Serve as a liaison between Humana UM operations and the State of Michigan regarding prior authorization reviews, prepayment retrospective reviews, and any additional utilization management functions. Coordinate with Humana’s Clinical Leadership teams to ensure utilization reviews comply with Centers for Medicare & Medicaid Services (CMS) regulations as well as Michigan Dual Special Needs Plan (DSNP) Contract terms. Work in conjunction with the Quality Improvement Director to develop quantifiable metrics that can track and evaluate the results of the targeted interventions designed to reduce health disparities and address health inequities. Manage Michigan state reporting and collaborate with the UM operations teams to aggregate and analyze data and reporting metrics. Provide quality support to the supervision and daily guidance of prior authorization associates ensuring outcomes that meet or exceed Humana and the Michigan Department of Health and Human Services (MDHHS) standards. Work in conjunction with Humana’s Medicare UM Committees to ensure adoption and consistent application of appropriate medical necessity criteria. Participate in oversight of the programs to ensure that Enrollees are accessing and utilizing services in an appropriate manner in accordance with all applicable rule and regulations. In conjunction with Humana's UM monitoring and oversight processes, monitors and analyzes Michigan DSNP specific outcomes. The analysis initiates action to implement appropriate interventions based on utilization data. This includes identifying and correcting over- or under-utilization of services, addressing issues with timeliness standards, ensuring appropriate Notice of Action is followed, and collaborating with Medical Directors. The collaboration ensures that the reason for denial, reduction, or termination is specific and clear. Ensure development and implementation of departmental policies and procedures in accordance with contract changes or updates. Provide oversight to ensure Humana maintains compliance with MDHHS, National Committee for Quality Assurance (NCQA), Department of Health and Human Services (DHHS), CMS guidelines and contractual requirements.

Requirements

• Must reside in or be willing to relocate to the state of Michigan.
• An active, unrestricted registered nurse (RN) license in the state of Michigan.
• Bachelor’s degree in nursing, health services, healthcare administration, business administration or a related field.
• Minimum five (5) years of clinical experience in utilization management.
• Minimum two (2) years of formal or informal leadership experience.
• Comprehensive knowledge of Microsoft Office applications including PowerPoint and Excel.
• Knowledge of Medicare regulatory requirements and National Committee for Quality Assurance (NCQA) standards.

Nice To Haves

• Master’s degree in nursing, health services, healthcare administration, business administration or a related field.
• Knowledge of Medicaid regulatory requirements.
• Experience with contracting, audit, risk management, or compliance.
• Proficiency in Power BI or comparable analytical tools.
• Experience in NCQA UM measures.

Responsibilities

• Interpret data, criteria, policies, and procedures to provide appropriate treatment, care, or services for members.
• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Analyze utilization management (UM) trends and drivers impacting member outcomes and financial impact in partnership with the Chief Medical Officer (CMO).
• Support quality efforts at the market and enterprise level to achieve quality targets in HEDIS, STARS, and NCQA accreditation.
• Advise executives to develop functional strategies on matters of significance.
• Exercise independent judgment and decision-making on complex issues regarding job responsibilities and related tasks.
• Serve as a liaison between Humana UM operations and the State of Michigan regarding prior authorization reviews, prepayment retrospective reviews, and other utilization management functions.
• Coordinate with Humana’s Clinical Leadership teams to ensure utilization reviews comply with Centers for Medicare & Medicaid Services (CMS) regulations and Michigan Dual Special Needs Plan (DSNP) Contract terms.
• Develop quantifiable metrics with the Quality Improvement Director to track and evaluate interventions designed to reduce health disparities and address health inequities.
• Manage Michigan state reporting and collaborate with UM operations teams to aggregate and analyze data and reporting metrics.
• Provide quality support to the supervision and daily guidance of prior authorization associates, ensuring outcomes meet or exceed Humana and MDHHS standards.
• Ensure adoption and consistent application of appropriate medical necessity criteria by working with Humana’s Medicare UM Committees.
• Participate in oversight of programs to ensure Enrollees access and utilize services appropriately in accordance with all applicable rules and regulations.
• Monitor and analyze Michigan DSNP specific outcomes in conjunction with Humana's UM monitoring and oversight processes.
• Initiate action to implement appropriate interventions based on utilization data, including identifying and correcting over- or under-utilization of services, addressing timeliness standards, ensuring appropriate Notice of Action is followed, and collaborating with Medical Directors.
• Ensure development and implementation of departmental policies and procedures in accordance with contract changes or updates.
• Provide oversight to ensure Humana maintains compliance with MDHHS, NCQA, DHHS, CMS guidelines, and contractual requirements.

Benefits

• Medical benefits
• Dental benefits
• Vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• Short-term disability
• Long-term disability
• Life insurance

What This Job Offers

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