RN Manager - Utilization Management - Southeast Region

Profile

Description

The Manager, Utilization Management Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Manager, Utilization Management Nursing works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.

Responsibilities

Where you Come In

We value people and if you succeed, we succeed! The Manager, Utilization Management 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 resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

Duties include:

Develop, Implement and maintain all activities and processes necessary to maintain compliance with NCQA and MMOC standards and regulatory requirements.

Work collaboratively with leadership to achieve and maintain compliance.

Collect and analyze data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals.

Provide open communication and perfect service to other departments, vendors, and providers throughout the region.

Weekly review of SCM nurses queues for compliance/ management of assignments.

Identify education needs of team. Work with QA Process Education team to meet identified opportunities to support the management and leadership of the department daily.

What Humana Offers

We are fortunate to offer a remote opportunity for this job. Our Fortune 100 Company values associate engagement & your well-being. We also provide excellent professional development & continued education.

Required Qualifications

2 or more years of managed care experience preferably utilization management

Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action

Progressive clinical experience preferably in an acute care, skilled or rehabilitation clinical setting

Ability to work independently under general instructions and with a team

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

Prior supervisory / management experience highly preferred

Bachelor's degree

Prior Medicare / Medicaid experience

Call center or triage experience

Bilingual is a plus

Additional Information

Must be able to work 8am-5pm EST hours

Scheduled Weekly Hours

40

Company info

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