Process Improvement Lead South Carolina Medicaid Utilization and Case Management

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Job Information
Humana
Process Improvement Lead South Carolina Medicaid (Utilization and Case Management)
in
Glen Allen
Virginia
Description
The Process Improvement Lead analyzes, and measures the effectiveness of existing business processes and develops sustainable, repeatable and quantifiable business process improvements. The Process Improvement Lead works on problems of diverse scope and complexity ranging from moderate to substantial.
Responsibilities
The Utilization Management (UM) and Case Management (CM) Process Improvement Lead for Behavioral Health and Physical Health analyzes and measures the effectiveness of existing business processes and develops sustainable, repeatable, and quantifiable business process improvements that focus on enhanced safety, increased productivity, and reduced cost. The Process Improvement Lead works on problems of diverse scope and complexity ranging from moderate to substantial and determines how new information technologies can support improved efficiency in UM and CM business processes.
Responsibilities
The UM and CM Process Improvement Lead will be primarily responsible for leading projects and user groups for Medical Management IT systems changes and enhancements, maintaining NCQA and State compliance and accreditation, and collaborating across the organization to ensure alignment between medical management, claims processing, claims cost containment and others. Working on Policies and procedures for UM and CM. Must be a self-starter, work independently with minimal direction, and possess the ability to prioritize multiple tasks effectively.
KEY ACCOUNTABILITIES
35% Lead and manage Medical Management Systems user group, develop project requirements and lead implementation, complete user end testing, and approve system changes.
25% Monitor UM and CM process and system changes to ensure compliance with NCQA standards, lead the submission of NCQA reaccreditation documentation, and prepare associates for onsite NCQA reaccreditation review.
20% Implement routine maintenance of UM and CM systems. Medical Management System enhancements, IT work groups
10% Create Standard Operating Procedures, update departmental policies and program descriptions
10% Perform other duties as required
Required Qualifications
Bachelor's degree or higher, Healthcare Management or related field
3 or more years of experience in utilization management processes, including medical necessity criteria and UM systems
2 or more years of project leadership experience
2 or more years of Medicaid Experience
Experience with NCQA to include leading re-accreditation activities
Experience with state audit, external quality review (EQR)
Strong analytical and problem solving skills
Ability to manage multiple priorities and work collaboratively across departments
Excellent written and verbal communication skills
Experience in identifying and effectively communicating actionable insights from data analysis
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.
Preferred Qualifications
Current RN or MSW license in state of employment
Additional 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 working outside of their homes.  
Please note: Some areas of our business, such as the Primary Care Organization including CenterWell, Conviva, Kindred at Home, onehome, SeniorBridge, Neighborhood Centers, Pharmacy Distribution Centers, and others, may be required to adhere to federal, state, or local or additional workplace guidelines. 
We continue to encourage all associates to become vaccinated, as vaccines remain the best and most effective defense against COVID-19. 
This policy applies to all associates who work outside of their homes which includes:
Work within our facilities
Interact directly with members and patients
Attend in-person meetings or training courses OR
Represent the organization at events or volunteer activities
Scheduled Weekly Hours
40

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