Utilization Management Nurse Lead

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 Utilization Management Nurse Lead uses clinical knowledge, communication skills, and independent critical thinking skills to interpret criteria, policies, and procedures that provide the best and most appropriate treatment, care, or services for Enrollees. The Utilization Management Nurse Lead coordinates and communicates with Providers, Enrollees, or other parties to facilitate optimal care and help drive quality outcomes for Humana's dual eligible members.

Serves as a liaison between Humana utilization management (UM) operations and the State of Michigan regarding prior authorization reviews, prepayment retrospective reviews, and any additional utilization management functions. Coordinates 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. Works in conjunction with the Quality Improvement Director to develop quantifiable metrics that can track and evaluate the results of the targeted interventions designed to reduce health disparities and address health inequities. Manages Michigan state reporting and collaborate with the UM operations teams to aggregate and analyze data and reporting metrics. Provides quality oversight to support 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. Works in conjunction with Humana’s Medicare UM Committees to ensure adoption and consistent application of appropriate medical necessity criteria. Participates in oversight of the programs to ensure that Enrollees are accessing and utilizing services in an appropriate manner in accordance with all applicable rule and regulations. In conjunction with Humana’s UM monitoring and oversight processes, monitors, analyzes, Michigan DSNP specific outcomes and initiates action to implement appropriate interventions based on utilization data, including but not limited to: identifying and correcting over- or under-utilization of services; addressing issues with timeliness standards; ensuring appropriate Notice of Action is followed; appropriate collaboration with Medical Directors to ensure reason for denial, reduction, or termination is specific and clear. Ensures development and implementation of departmental policies and procedures in accordance with contract changes or updates. Provides 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.