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Utilization Management Nurse Lead - Remote

Posted 3 days ago
All others
Full Time
MI, USA
$94,900 - $130,500/year

Overview

The Utilization Management Nurse Lead plays a crucial role in ensuring optimal care for Humana's dual eligible members by utilizing clinical knowledge and communication skills to interpret treatment criteria and policies.

In Short

  • Lead utilization management operations for dual eligible members.
  • Coordinate care with providers and enrollees.
  • Ensure compliance with CMS regulations and state contract terms.
  • Develop metrics to track quality outcomes.
  • Oversee prior authorization associates and their outcomes.
  • Monitor and analyze utilization data for interventions.
  • Participate in quality assurance and compliance activities.
  • Manage Michigan state reporting and collaborate with operations teams.
  • Provide training and guidance to team members.
  • Occasional travel within Michigan for meetings and training.

Requirements

  • Active RN license in Michigan.
  • Bachelor’s degree in nursing or related field.
  • 5 years of clinical experience in utilization management.
  • 2 years of leadership experience.
  • Knowledge of Medicare and NCQA standards.
  • Proficient in Microsoft Office applications.
  • Master’s degree preferred.
  • Experience in compliance or risk management is a plus.

Benefits

  • Comprehensive medical, dental, and vision benefits.
  • 401(k) retirement savings plan.
  • Paid time off and holidays.
  • Short-term and long-term disability coverage.
  • Life insurance and other opportunities for personal wellness.

H.A.H.

Humana At Home 1

004 Humana Insurance Company is dedicated to putting health first for its teammates, customers, and the communities it serves. As a leading provider of insurance and healthcare services, Humana focuses on improving the quality of life for millions of individuals, including those with Medicare and Medicaid, families, and military personnel. The company emphasizes a holistic approach to well-being, offering a range of benefits designed to support personal wellness and smart healthcare decisions. Humana is committed to fostering an inclusive workplace and actively promotes equal opportunity for all employees.

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