Location: KY
Location Type: Remote
Schedule: Full_time
Req: R-347243

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

The Manager, Pre-Authorization Nursing oversees the UM nurses who complete the medical necessity and level of care reviews for requested outpatient services and the UM coordinators who support the clinical team in daily operations. The UM manager is responsible to educate providers on utilization and medical management processes for KY Medicaid. This professional is also responsible to review and document compliance to our KY Medicaid state contract requirements and NCQA guidelines for all direct reports.

 

The Manager, Pre-Authorization Nursing

• Oversees the UM nurses who complete the medical necessity and level of care reviews for requested outpatient services and the UM coordinators who support the clinical team in daily operations
• Responsible to educate providers on utilization and medical management processes
• Responsible to review and document compliance to our KY Medicaid state contract requirements and NCQA guidelines for all direct reports
• Works collaboratively with the compliance team to review compliance audits for direct reports and coach direct reports appropriately based on audit results
• Ability to interpret reports, provide analysis and action planning based on trends
• Responsible for collaborating with KY MCD PH UM leaders and RMDs to align on strategies for meeting productivity goals and metrics
• Requires cross departmental collaboration, and conducts briefings and area meetings
• Maintains frequent contact with other managers across the department

Use your skills to make an impact

Required Qualifications

• Licensed Registered Nurse (RN) in the state of Kentucky with no disciplinary action and ability to be licensed in multiple states without restriction.
• 2+ years of Utilization Management experience in a managed care setting.
• 2+ years of management/leadership, project lead or subject matter expert experience
• 2+ years of progressive clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
• Strong Proficiency with MS Office Suite to include Word, Excel, Power Point.
• Experience with the development and implementation of policies and procedures
• Ability to work independently under general instructions and with a team

Additional Requirements:

• Hours: Typically Monday-Friday 8:00 AM – 5:00 PM with rotating on-call coverage and oversight during weekends and holidays
• Location: WAH with expectation to attend in person meetings, trainings, associate engagement activities
• Completion of a Level II; AHCA Fingerprinting

Preferred Qualifications

• Bachelor’s Degree
• Prior supervisory experience hiring, training, coaching, and termination
• Health Plan experience
• Medicaid experience

Work at Home Requirements

• 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.
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates 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, we will be using an exciting interviewing technology provided by HireVue, a third-party vendor.  This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded SMS Text Messaging interview.  You will be asked a series of questions to which you will be using your cell phone to answer the questions provided.  Expect this type of interview to last anywhere from 5-10 minutes. Your text responses will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

 

Social Security Task

Alert: Humana values personal identity protection.  Please be aware that applicants being considered for an interview will be asked to provide a social security number, if it is not already on file.  When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana’s secure website.

 

Scheduled Weekly Hours

 

40

 

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

 

$84,600 – $116,300 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

 

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

 

Equal Opportunity Employer

 

It is the policy of  Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of  Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.