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Associate Director, Utilization Management Nursing - Oklahoma City, OK Humana - Oklahoma City, OK

Company: Humana
Location: Oklahoma City
Posted on: November 18, 2021

Job Description:



The Associate Director, Utilization Management Nursing uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment.

Responsibilities



  • Serves as a liaison between Humana and the State regarding Prior Authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.

  • Coordinates with the Clinical Leadership team to ensure all utilization reviews are in compliance with the terms of the Medicaid contract.

  • Provide supervision and daily guidance to prior authorization team members ensuring that the service provided meets or exceeds clinical and procedural and Oklahoma Health Care Authority (OHCA) standards.

  • Ensure adoption and consistent application of appropriate medical necessity criteria.

  • Monitor, analyze, and implement appropriate interventions based on utilization data, including identifying and correcting over- or under-utilization of services.

  • Oversee prior authorization functions and assure that decisions are made in a timely and consistent manner based on clinical criteria and meet timeliness standards to ensure appropriate Notice of Action is followed including collaboration with the Medical Director to ensure reason for denial, reduction, or termination is specific and clear.

  • Develop and implement departmental policies and procedures in accordance with contract changes and/or updates.

  • Maintain compliance with Oklahoma Health Care Authority (OHCA), Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.




    Required Qualifications


    • Unrestricted Registered Nurse (RN) license in the state of Oklahoma.

    • BSN, Bachelor's Degree in health services, healthcare administration, or business administration preferred.

    • Minimum five (5) years of previous clinical experience.

    • Minimum two (2) years of leadership experience.

    • Comprehensive knowledge of Microsoft Office applications including, PowerPoint Word, Excel, and Outlook.

    • Knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards.

    • Must have a separate room with a locked door that can be used as a home office, to ensure you have absolute and continuous privacy while you work.

    • Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.

    • Must live within 25 miles of Oklahoma City, OK.



      Additional Information



      • Days/Hours: Monday - Friday; 8:30am - 5:00pm, Central Standard Time.



      • Travel: Some travel in the state of Oklahoma. (There will be no travel at this time due to business travel restrictions).


      • Work Location: Office based but temporarily remote. In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include:Access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, Dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves. The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process.




        Interview Format

        As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire/Montage, 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 Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.


        If participating in a SMS Text 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 recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.


        Scheduled Weekly Hours

        40

Keywords: Humana, Oklahoma City , Associate Director, Utilization Management Nursing - Oklahoma City, OK Humana - Oklahoma City, OK, Executive , Oklahoma City, Oklahoma

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