Associate Director Utilization Management Nursing Ohio Medicaid - Remote Ohio

Profile

Description

The Associate Director, 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.

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 Ohio Department of Medicaid (ODM) 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.
Oversee prior authorization functions and assure that decisions are made in a timely and consistent manner based on clinical criteria and meet timeliness standards to ensure appropriate Notice of Action is followed including collaboration with the Medical Director to ensure reason for denial, reduction, or termination is specific and clear.
Develop and implement departmental policies and procedures in accordance with contract changes and/or updates.
Maintain compliance with Ohio Department of Medicaid (ODM), NCQA, Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.


Required Qualifications


Unrestricted Registered Nurse (RN) license in the state of Ohio.
Bachelor's Degree in health services, healthcare administration, or business administration preferred.
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.
Must reside in the state of Ohio.
This role is 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 a room in your home designated as a home office; away from high traffic areas where confidential information may be secured.
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


Master's Degree in nursing, public health, health administration, health policy or business.
Knowledge of Humana's internal policies, procedures and systems.


Additional Information


Travel: up to 25% to Columbus, OH and vicinity.
Direct Reports: up to 8 Associates.


Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Montage/Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Company info

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