Associate Director, Utilization Management Nursing - Va Medicaid

Become a part of our caring community and help us put health first.

Humana Healthy Horizons in Virginia is seeking an Associate, Director, Utilization Management who will use 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 members. They will coordinate and communicate with Providers, Members, or other parties to facilitate optimal care and treatment.

• Serves as a liaison between Humana and the Commonwealth regarding prior authorization reviews, prepayment retrospective reviews, and any additional Utilization Management functions.
• Coordinates with the Clinical Leadership team to ensure all utilization reviews comply with Medicaid Contract terms.
• Provides supervision and daily guidance to prior authorization associates ensuring that the service provided meets or exceeds clinical, procedural, and the Virginia Department of Medical Assistance (DMAS) standards.
• Ensures adoption and consistent application of appropriate medical necessity criteria.
• Oversees the Patient Utilization Management & Safety (PUMS) Program to ensure that members are accessing and utilizing services in an appropriate manner in accordance with all applicable rule and regulations.
• Monitors, analyzes, and implements appropriate interventions based on utilization data, including identifying and correcting over- or under-utilization of services.
• Oversees prior authorization functions and ensures that decisions are made in a timely and consistent manner based on clinical criteria and meets timeliness standards to ensure appropriate Notice of Action is followed including collaboration with the Medical Director to ensure reason for denial, reduction, or termination is specific and clear.
• Develops and implements departmental policies and procedures in accordance with contract changes or updates.
• Maintains compliance with DMAS, NCQA, Department of Health and Human Services (DHHS), and the Centers for Medicare & Medicaid Services (CMS) guidelines and contractual requirements.

Use your skills to make an impact.

Required Qualifications

• Must reside in the state of Virginia.
• An active, unrestricted Registered Nurse (RN) license in the state of Virginia.
• BSN, bachelor’s degree in health services, Healthcare Administration, or Business Administration.
• Minimum five (5) years of previous clinical experience in Utilization Management.
• Minimum three (3) years of leadership experience.
• Comprehensive knowledge of Microsoft Office applications including PowerPoint, Word, Excel, and Outlook.
• Knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards.

Preferred Qualifications

• Master’s degree.

Additional Information

• Workstyle: This is a remote position that requires you to travel to Humana Healthy Horizons' Glen Allen, Virginia office location for collaboration and occasional meetings.
• Typical Days & Hours:Monday – Friday; 8:00am – 5:00pm.

Work at Home Criteria

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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.
• Humana will provide Home or Hybrid Home/Office employees 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.

Interview Format

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

Scheduled Weekly Hours: 40

(R-331932/JoniW)

Job Type: Full-time

Pay: $102,200.00 - $128,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Application Question(s):

• REQUIIRED: Do you have comprehensive knowledge of Microsoft Office applications including PowerPoint, Word, Excel, and Outlook? Yes or No
• REQUIRED: Do you have knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards? Yes or No
• Have you ever worked for Humana, CenterWell, or Enclara? Yes or No

Education:

• Bachelor's (Required)

Experience:

• Utilization Management: 5 years (Required)
• Leadership: 3 years (Required)

License/Certification:

• Active Virginia Nurse (RN) License (Required)

Work Location: Remote