Associate Director Utilization Management

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Job Information
Humana
Associate Director Utilization Management
in
Tampa
Florida
Description
Come join our team. We are looking for an Associate Director, Utilization Management to utilize clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Associate Director, Utilization Management requires a solid understanding of how organization capabilities interrelate across department(s).
Responsibilities
The Associate Director, Utilization Management 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 identifying and resolving complex technical and operational problems within department(s), and could lead multiple managers or highly specialized professional associates. The Associate Director of Utilization Management Nursing will:
Lead a team of Associates who perform concurrent review in acute and non-acute facilities at the member's bedside.
Participate in the development of and adherence to the measurement, evaluation, and implementation of productivity goals, including audit functions, field shadowing, utilization indicator tracking and performance monitoring tools.
Monitor and identify challenges and provide support with new lines of business and process changes to ensure staff is meeting goals and adhere to state, federal, and accreditation requirements as well as company policies.
Collaborate with Provider Operations in the establishment and maintenance of physician and facility relationships, including education, in-services and issue resolution, via telephone and through periodic on-site visits.
Improve operational performance, efficiency, and effectiveness.
Improve processes and procedures to maximize impact to member's health and outcomes.
Support compliance with all mandated reporting and regulatory requirements to ensure CPHP and HSO performance.
Working knowledge of MCG guidelines and all UM requirements.
Develop strategic initiatives to improve quality, expense, and performance measures
Support the implementation and ongoing efforts of performance improvement plans to address variances.
Monitors and oversees the South Florida FCM's, After-hours/weekend clinical advisor, and Inpatient coordinators, areas within the department to ensure that all Federal, State and Local compliance requirements are met to the highest standard.
Identifies and works with the Medical Directors and Team Managers in the development and implementation of medically indicated programs to facilitate improved utilization results and health outcomes.
Actively plans and participates in departmental budgetary matters.
Participates and leads corporate and departmental committees and workgroups
Other duties as assigned by the Health Services Director.​
Required Qualifications
Bachelor's Degree and Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action or Associates degree paired with 3 years of leadership experience.
3 years clinical experience in acute care
3 - 5 years' experience in utilization management, including discharge planning, concurrent review and/or home health or rehab is required
Working knowledge of vendor management (i.e. home health DME/infusion)
Prior Experience in working with hospitalists groups and field case management
Progressive experience in the health solutions industry, with emphasis on leading and managing teams
Proficiency in analyzing and interpreting financial trends, utilization indicators and develop strategic plans to address needs
Previous Medicare/Medicaid experience
Previous Health Plan experience
Comprehensive knowledge of all Microsoft Office applications, including Word, Excel and Access
Valid driver's license and/or dependable transportation necessary
Preferred Qualifications
Strong knowledge of Dade, Broward and Palm Beach County facilities and networks (hospitals, SNFs, LTACs)
Experience managing managers/supervisors
Additional Information
This position will be working remote in Florida but with the ability to work in Doral or Tampa facilities.
Must have accessibility to high speed DSL or cable modem for a home office (satellite internet service is NOT allowed for this role); and a minimum internet connection speed of 10M x 1M
Interview Format
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate in a Montage Voice interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
40

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