Director Utilization Management Behavioral Health Nursing

Profile

Description

The Director, Health Services Nursing serves as the strategic leader for Humana Behavioral Health Utilization Management Inpatient services - including all clinical (inpatient and some OP medical necessity oversight ) decisions, as well as serving as a key partner in building out clinical capabilities. The Director will be responsible for driving change to meet /exceeding targets related to clinical outcomes and financial stewardship

Responsibilities

The Director, Utilization Management Behavioral Health Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of behavioral health services and/or benefit administration determinations. The Director, Utilization Management Behavioral Health Nursing requires an in-depth understanding of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan . This role will support both Commercial, Medicare and DSNP lines of business.

The Director, Utilization Management Behavioral Health Nursing uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy. It is critical this leader start with curiosity and empower professionals to work at the top of their license, while supporting a balance of performance management.

Additional Responsibilities

Department oversight and leadership of 120 stateside associates

Effective communication skills; ability to speak with line associates and deliver presentations to senior leaders of Humana

Demonstrated capability with coaching and developing associates formally and informally in a remote setting

Proven leadership, development, coaching and performance management of large teams

Experience with prioritizing and balancing multiple responsibilities and projects

Effective communication skills; ability to speak with line associates and deliver presentations to senior leaders of Humana

Requires deep expertise in utilization management processes acute and post-acute.

Ability to toggle between strategy and operations, with a strong desire to engage and provide leadership for both.

Ability to go from strategy and planning to implementation while thoughtfully managing change.

Knowledge of clinical care standards and performance benchmarks.

Exceptional soft skills such as relationship building, communication, listening, negotiation and diplomacy.

Drive execution of key initiatives to ensure Further simplify and improve processes

Oversight of timeliness of all prospective reviews.

Collaborate with various internal and external teams

25% travel once restrictions are lifted

Required Qualifications

5 or more years of management experience

Nursing license is required

Deep understanding in Compliance/Risk/ Policies specific to Medicare/Commercial

Support and drive positive associate engagement

Agile change leader

Collaborative - when to lean on subject matter experts, teammates and leaders

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

Master's Degree strongly preferred

Additional Information

Scheduled Weekly Hours

40

Company info

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