Utilization Management Nurse Lead

About the role

The Utilization Management Nurse Lead plays a crucial role in interpreting data, criteria, policies, and procedures to ensure the best and most appropriate treatment, care, or services for members. This role involves coordinating and communicating with providers, members, or other parties to facilitate optimal care and treatment. The lead works closely with the Chief Medical Officer to analyze utilization management trends and drivers impacting member outcomes and financial impact. They also support quality efforts at both the market and enterprise levels to achieve quality targets in HEDIS, STARS, and NCQA accreditation.

Responsibilities

• Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.
• Support quality efforts at both the market and enterprise levels to achieve quality targets in HEDIS, STARS, and NCQA accreditation.
• Advise executives to develop functional strategies on matters of significance.
• Exercise independent judgment and decision making on complex issues regarding job responsibilities and related tasks, working under minimal supervision.
• Serve as a liaison between Humana UM operations and the State of Michigan regarding prior authorization reviews, prepayment retrospective reviews, and additional utilization management functions.
• Coordinate with Humana’s Clinical Leadership teams to ensure utilization reviews comply with Centers for Medicare & Medicaid Services (CMS) regulations as well as Michigan Dual Special Needs Plan (DSNP) Contract terms.
• Work in conjunction with the Quality Improvement Director to develop quantifiable metrics that can track and evaluate the results of targeted interventions designed to reduce health disparities and address health inequities.
• Manage Michigan state reporting and collaborate with the UM operations teams to aggregate and analyze data and reporting metrics.
• Provide quality support to the supervision and daily guidance of prior authorization associates ensuring outcomes that meet or exceed Humana and the Michigan Department of Health and Human Services (MDHHS) standards.
• Participate in oversight of the programs to ensure that enrollees are accessing and utilizing services in an appropriate manner in accordance with all applicable rules and regulations.
• Collaborate with Humana’s Medicare UM Committees to ensure adoption and consistent application of appropriate medical necessity criteria.
• Ensure development and implementation of departmental policies and procedures in accordance with contract changes or updates.
• Provide oversight to ensure Humana maintains compliance with MDHHS, National Committee for Quality Assurance (NCQA), Department of Health and Human Services (DHHS), CMS guidelines and contractual requirements.

Requirements

Must reside in or be willing to relocate to the state of Michigan. Must have an active, unrestricted registered nurse (RN) license in the state of Michigan. Must have a Bachelor’s degree in nursing, health services, healthcare administration, business administration or a related field. Minimum five (5) years of clinical experience in utilization management. Minimum two (2) years of formal or informal leadership experience. Comprehensive knowledge of Microsoft Office applications including PowerPoint and Excel. Knowledge of Medicare regulatory requirements and National Committee for Quality Assurance (NCQA) standards.

Preferred Qualifications

• A Master’s degree in nursing, health services, healthcare administration, business administration or a related field.
• Knowledge of Medicaid regulatory requirements.
• Experience with contracting, audit, risk management, or compliance.
• Proficiency in Power BI or comparable analytical tools.
• Experience in NCQA UM measures.