Associate Director, Health Services

South Carolina, United States

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Not SpecifiedCompensation

Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Health Services, Managed CareIndustries

Requirements

Candidates must possess a Bachelor's degree in nursing, public health, health administration, health policy, or business. A minimum of 3 years of leadership experience in utilization management, including familiarity with InterQual, MCG, and/or ASAM criteria, is required. Additionally, 3 years of care management leadership experience and 3 years of Medicaid-related experience are necessary, along with comprehensive knowledge of Microsoft Office applications. An unrestricted RN license in South Carolina with no disciplinary action is preferred.

Responsibilities

The Associate Director, Health Services will provide strategic leadership for utilization management, population health, care coordination, and case management. They will lead efforts to improve member and provider experiences, oversee the assessment of member needs, and coordinate with the Clinical Leadership team to ensure compliance with Medicaid contracts. Responsibilities include supervising care management and utilization management teams, ensuring adherence to medical necessity criteria, monitoring performance metrics, developing departmental policies, and participating in audit preparations. The role also involves developing team members, creating process flows, leading managers, and facilitating cross-departmental collaboration to optimize member outcomes and operational efficiencies.

Skills

Utilization Management

Population Health

Care Coordination

Case Management

Clinical Capabilities

Medical Necessity Criteria

NCQA Standards

Medicaid Contract Compliance

Policy Development

Performance Metrics Monitoring

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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