UM/PA Nurse Supervisor

Employment Type: Full-time

Position Overview

Become a part of our caring community and help us put health first. The UM/PA Nurse Supervisor plays a key leadership role in overseeing the daily operations of the Utilization Management and Pre-Authorization nursing teams. This position ensures timely and accurate review of medical necessity and appropriateness of care, in alignment with clinical guidelines, regulatory requirements, and organizational policies. The Supervisor provides frontline support to nursing staff, facilitates interdepartmental collaboration, and assists in managing workload distribution and performance metrics. In addition to supervising clinical review processes, the UM/PA Nurse Supervisor contributes to staff development, quality improvement initiatives, and operational efficiency. This role serves as a liaison between clinical teams, providers, and internal stakeholders, ensuring a high standard of service delivery and compliance.

Responsibilities

• Provide daily operational support and guidance to Utilization Management (UM) and Pre-Authorization (PA) nursing staff.
• Conduct monthly one-on-one check-ins with team members to support performance, development, and engagement.
• Maintain and update staff training materials and departmental resources to ensure consistency and compliance.
• Coordinate updates to letter templates in collaboration with Compliance, Network Development, and IT, ensuring alignment with CMS and DHS requirements and proper integration into TruCare.
• Support NCQA re-accreditation efforts by implementing updated processes and policies to meet accreditation standards.
• Assist in leading bi-weekly departmental and team meetings to promote communication, alignment, and continuous improvement.
• Review PA requests for services including home health, durable medical equipment, outpatient therapies, skilled nursing facility therapies, and outpatient procedures, ensuring compliance with Medicare, Medicaid, iCare guidelines, and departmental policies.
• Evaluate PA requests for inpatient stays (acute, skilled nursing, LTAC, and rehabilitation) in accordance with Humana/iCare protocols, and collaborate with discharge planners, care coordinators, and behavioral health staff to support member transitions.
• Monitor inpatient and subacute activity daily, assessing outcomes related to readmissions, utilization, quality of care, and provider performance in accordance with organizational policies.
• Document clinical decisions accurately, including rationale for approvals or referrals to the Reviewing Medical Director.
• Draft reduction and denial letters based on medical director reviews and applicable clinical guidelines.
• Maintain up-to-date knowledge of Medicare and Medicaid regulations and apply changes to departmental practices as needed.
• Collaborate with PA staff to ensure timely and efficient completion of departmental workflows.
• Contribute to the development and refinement of departmental programs, policies, and procedures.
• Lead or participate in special projects and initiatives as assigned.
• Use your skills to make an impact.

Requirements

• Licensed as a Registered Nurse in the State of Wisconsin, including compact license.
• Two (2) or more years of experience in clinical care.
• Proficiency with Microsoft Office applications, specifically Word, Excel, and Outlook.
• At least 3-years experience with prior authorization/utilization management.

Preferred Qualifications

• Bachelor of Science in Nursing
• Previous leadership experience
• Knowledge of Milliman (MCG) or InterQual.
• Knowledge of TruCare.
• Managed Care experience.

Additional Information

• Workstyle: Home. Home workstyle is defined as remote but will use Humana office space on an as needed basis for collaboration and other face-to-face needs.
• Typical Work Days/Hours: Monday through Friday, 8:30 am – 5:00 pm Central Standard Time (CST).
• WAH Internet Statement: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office...

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