Utilization Management Nurse Lead

Michigan, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, Managed CareIndustries

Requirements

Candidates must reside in or be willing to relocate to Michigan and possess an active, unrestricted registered nurse (RN) license in Michigan. A Bachelor's degree in nursing, health services, healthcare administration, business administration, or a related field is required, along with a minimum of five years of clinical experience in utilization management and at least two years of leadership experience. Proficiency in Microsoft Office applications (PowerPoint, Word, Excel, Outlook) and knowledge of Medicare regulatory requirements and NCQA standards are essential. A Master's degree in a related field, knowledge of Medicaid regulations, and experience with contracting, audit, risk management, or compliance are preferred.

Responsibilities

The Utilization Management Nurse Lead will utilize clinical knowledge and critical thinking to interpret criteria and policies for optimal treatment and care for enrollees. This role involves coordinating with providers and enrollees to facilitate care and improve outcomes for dual-eligible members. The lead will serve as a liaison between Humana UM operations and the State of Michigan for utilization reviews, manage state reporting, and analyze data. They will provide quality oversight and guidance to prior authorization associates, ensuring adherence to Humana and MDHHS standards. Additionally, the lead will collaborate with clinical leadership and UM committees to ensure compliance with CMS regulations and contract terms, oversee programs for appropriate service utilization, and develop and implement departmental policies and procedures in accordance with contract changes.

Skills

Utilization Management

Clinical Knowledge

Communication Skills

Critical Thinking

Prior Authorization

Data Analysis

Quality Improvement

CMS Regulations

Medicare

Medical Necessity Criteria

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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