Manager Utilization Management Nursing Ohio Medicaid - Remote Ohio

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Job Information

Humana

Manager, Utilization Management Nursing (Ohio Medicaid) - Remote, Ohio

in

Cincinnati

Ohio

Description

Humana Healthy Horizons in Ohio 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 S.M.A.R.T 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 Ohio with no disciplinary action.

Must reside in the state of Ohio.

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 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 a separate room with a locked door that can be used as a home office, to ensure you have absolute and continuous privacy while you work.

Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.

For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.

If progressed to offer, you will be required to: Provide proof of full vaccination OR

Commit to weekly testing, following all CDC protocols, OR

Provide documentation for a medical or religious exemption consideration. This policy will not supersede state or local laws. Requests for these exemptions should be submitted at least 2 weeks prior to your scheduled first day of work.

Preferred Qualifications.

BSN, Bachelor's degree in health services, healthcare administration, or related field.

Fluency in Spanish or Somali.

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.

Travel:

Up to 25% in-state travel.

Typical Work Days/Hours:

Mon - Friday; 8:00am - 5:00pm with potential rotating on-call schedule.

Direct Reports:

up to 15 associates.

Additional Information

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

Company info

Humana Inc.
Website : http://www.humana.com