Manager National Medicaid Utilization Management Operations Manager

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

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.

Detailed Responsibilities include:

Leads National Medicaid Utilization Management process and teams responsible for supporting new Medicaid Market Clinical Operations delivery including:


Supporting team that delivers Clinical Prior Authorization policies, processes, detailed workflows, and leading the Centralized Utilization Management Outpatient operations team;
Leading a team of Utilization Management nurses and support staff responsible for reviewing and processing clinical authorizations and clinical claims reviews;
Supporting development of IT business requirements and training content for administering utilization management process in Humana's clinical systems;
Assist in developing Utilization Management reporting requirements to assure operational oversight and address state reporting requirements for supporting all Medicaid states;
Implementing operational support tools and identifying operational best practices and process opportunities;
Assuring compliance with state timeframes for turnaround times on authorization requests and delivery of Utilization Management services.
Participate in on-call rotation program to provide after hours, 24/7 clinical coverage requirements.


Required Qualifications

*Bachelor's Degree in Nursing;

*Active Compact Registered Nurse license, without restrictions or disciplinary action;

*4 years of Utilization Management experience

*2 years of Managed Care experience

*2 years of Utilization Management leadership experience

*Recent working knowledge and familiarity with MCG medical criteria and administering clinical practice guidelines

*Ability to participate in on-call rotation program to provide after hours, 24/7 clinical coverage requirements

Preferred Qualifications

*Previous Medicaid experience

Additional Information

This position is open to working remote (with the ability to work and support the Eastern Time Zone)

Scheduled Weekly Hours

40

Company info

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