RN, Manager, Utilization Management Nursing

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

The Manager, Utilization Management Nursing (LTSS Utilization Management Leader) 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.

Responsible for providing leadership and oversight of the physical health utilization management (UM) staff in daily operations. Uses clinical knowledge, communication skills, and independent critical thinking skills toward interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for members. Hire, train, coach, counsel and evaluate performance of direct reports. Implements and maintain processes that are compliant with the Michigan Department of Health and Human Services (MDHHS) and National Committee for Quality Assurance (NCQA) guidelines. Works collaboratively with UM leadership to assess and mitigate inefficiencies and provide solutions to improve clinical outcomes. Collect and analyze data as necessary to drive operational metrics and associate performance. Coordinate and communicate with Providers, Members, or other parties to facilitate optimal care and treatment. Makes decisions that are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Facilitate cross-departmental collaboration and conduct briefings and area meetings; maintain frequent contact with other managers across functional areas.