Manager, Utilization Management Nursing

Become a part of our caring community. The Manager, Utilization Management Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations.

About the role

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. 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.

Responsibilities

• Utilize clinical nursing skills to support coordination, documentation, and communication of medical services or benefit administration determinations.
• Interpret criteria, policies, and procedures to ensure appropriate treatment, care, or services for members.
• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Collaborate across departments and conduct briefings or meetings.

Requirements

• Active Licensed Registered Nurse (RN) in Virginia or enhanced compact license (eNLC) with no disciplinary action.
• Minimum 2 years of team lead and/or project lead experience.
• Minimum 2 years progressive clinical experience preferably in an acute care, skilled, or rehabilitation setting.
• Intermediate to Advanced knowledge using Microsoft Office (Word, Excel, PowerPoint), navigating multiple systems and platforms, and ability to troubleshoot and resolve basic technical difficulties in a remote environment.
• Ability to work independently under general instructions and with a team.
• Reside in a state participating in a compact license (eNLC).

Qualifications

• Bachelor's Degree (preferred).
• Prior supervisory experience which may include interviewing, hiring, training, performance evaluation, coaching, and up to termination.
• Utilization management experience.
• Prior experience within discharge planning or case management.
• Health Plan experience.
• Prior Medicare/Medicaid experience.
• Call center or triage experience.
• Bilingual is a plus.

Schedule

• Must work a minimum of 8 hours between 8:00 AM to 5:00 PM Eastern Time.
• May be required to work rotating holidays or weekends as determined by business needs.
• Scheduled weekly hours: 40.

Workstyle

Remote work at home.

Work at Home Requirements

• Self-provided internet service must meet the following criteria: minimum download speed of 25 Mbps and upload speed of 10 Mbps; wireless, wired cable, or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.

Travel

• Less than 10% for onsite market as business needs.
• Occasional travel to Humana's offices for training or meetings may be required.

Pay

The pay range reflects a good faith estimate of starting base pay for full-time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job-related skills, knowledge, experience, education, and certifications.

$94,900 - $130,500 per year.

This job is eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Time off, including paid time off, company and personal holidays, paid parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance.
• Additional opportunities designed to encourage personal wellness and smart healthcare decisions.