Location
Portland, ME, United States
Posted on
Jun 28, 2021
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
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