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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.

The Manager is responsible for ensuring high quality, cost-effective, and appropriate allocation of member services, treatments, and resources. The Manager serves as a resource to Humana’s management team, members, and outside medical providers and vendors.

• Effectively manages attendance, schedules, assignments, and compliance expectations to ensure adequate coverage during traditional and nontraditional business hours (weekend, evenings, and holidays as applicable) to support the needs of the business

• Provides oversight, education, support, and coaching to ensure associates' performance meets expectations and regional operational goals/metrics

• Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions

• Support the daily management and operations of the department. Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services.

• Implements and executes policies and processes necessary to support the business need and maintain compliance with regulatory requirements

• Analyzes operational and analytical reports to monitor and track operational efficiency

• Ability to perform case reviews. Properly documents utilization management activities and rationale for all decisions in electronic medical records systems

• Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management

• Additional duties as assigned

Use your skills to make an impact

Required Qualifications

• Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action

• 3+ years of progressive clinical experience preferably in an acute care, hospital, skilled or rehabilitation clinical setting

• Utilization Management experience is required for this role

• Strong attention to detail, excellent time management and organizational skills

• Excellent communication skills both verbal and written

• Proficient with Microsoft Word, Outlook and Excel

• Ability to work independently under general instructions and with a team

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Bachelor’s degree in nursing (BSN)

• Prior supervisory or leadership experience is highly preferred

• Experience in a team lead/SME or trainer/preceptor role

• Health Plan experience

• Previous Medicare experience a plus

• MCG experience preferred

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information

• Hours are: Monday-Friday 8am-5pm MST or PST (Weekend and Holiday work is required based on a business need, leaders rotate weekend coverage)

• 10%-15% of travel may be required in the future based on business needs

• This role will have 12-15 direct reports

Scheduled Weekly Hours

40

Pay Range

The compensation range below 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, certifications, etc.

$84,600 - $116,300 per year

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

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

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.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.