Associate Director Utilization Management Nursing - Louisiana Medicaid

Profile

Description

Humana Healthy Horizons in Louisiana is seeking an Associate Director, Utilization Management Nursing who will use clinical knowledge, communication skills, and independent critical thinking skills to provide the best and most appropriate treatment, care or services for members. He/she will lead teams of nurses and behavioral health professionals responsible for utilization management. The Associate Director, Utilization Management Nursing requires a solid understanding of how organization capabilities interrelate across department(s). They will coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.

Responsibilities

Serves as a liaison between Humana and the State regarding Prior Authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.

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 prior authorization team members ensuring that the service provided meets or exceeds clinical and procedural and Louisiana Department of Health (LDH) standards.

Ensure adoption and consistent application of appropriate medical necessity criteria.

Monitor, analyze, and implement appropriate interventions based on utilization data, including identifying and correcting over- or under-utilization of services.

Will directly lead multiple managers and highly specialized professional associates.

Oversee inpatient utilization management functions for physical health and behavioral health; ensure that decisions are made in a timely and consistent manner based on clinical criteria and meet timeliness standards

Develop and implement departmental policies and procedures in accordance with contract changes and/or updates.

Maintain compliance with Louisiana Department of Health (LDH), NCQA, Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.

Required Qualifications

Must reside in the state of Louisiana.

Unrestricted Registered Nurse (RN) license in the state of Louisiana.

Minimum five (5) years of previous clinical experience in utilization management.

Minimum three (3) years of leadership 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.

This role is a part of Humana's Driver Safety program and therefore requires an individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.

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 25x10 (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.

Preferred Qualifications

Bachelor's or Master's Degree in nursing, public health, health administration, health policy or business.

Knowledge of Humana's internal policies, procedures and systems.

Additional Information

Workstyle : Hybrid Home - Works 1 - 2days/week in Humana's Baton Rouge or Metairie, LA office location and 3 - 4 days remotely.

Travel: up to 25% in the state of Louisiana.

Direct Reports: up to 8 Managers/Associates.

Scheduled Weekly Hours

40

Company info

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