Manager, Utilization Management – Nursing

This is a fully remote position, open to applicants in United States.

📋 Description

• Assist in the coordination, documentation, and communication regarding medical services and benefit administration decisions.

• Analyze clinical criteria, policies, and procedures to ascertain suitable treatment, care, or services for members.

• Facilitate communication and coordination with providers, members, and other stakeholders to ensure optimal care and treatment.

• Identify strategies, resources, timelines, and objectives for departmental projects and initiatives.

• Address moderately complex issues utilizing advanced technical expertise.

• Collaborate with various departments.

• Conduct briefings and area meetings.

• Maintain regular communication with managers throughout the department.

• Lead and support nursing operations related to utilization management.

⛳️ Requirements

• Active Licensed Registered Nurse (RN) in Virginia or enhanced compact license (eNLC) without any disciplinary actions.

• At least 2 years of experience in a team lead or project lead role.

• Minimum of 2 years of progressive clinical experience, ideally in an acute care, skilled, or rehabilitation environment.

• Proficient in Microsoft Office applications, including Word, Excel, and PowerPoint at an intermediate to advanced level.

• Capable of navigating various systems and platforms.

• Skilled in troubleshooting and resolving basic technical issues in a remote setting.

• Able to work independently with general guidance as well as collaboratively within a team.

• Reside in a state that participates in the enhanced compact license (eNLC).

• Available to work a minimum of 8 hours between 8:00 AM and 5:00 PM Eastern Time.

• Willing to work rotating holidays or weekends based on business requirements.

• Must have a minimum download speed of 25 Mbps and an upload speed of 10 Mbps for home internet.

• Capable of working from a dedicated space free from interruptions to protect member PHI/HIPAA information.

• Preferred: Bachelor's Degree.

• Preferred: Previous supervisory experience, encompassing interviewing, hiring, training, performance evaluation, coaching, and termination.

• Preferred: Experience in utilization management.

• Preferred: Background in discharge planning or case management.

• Preferred: Experience in a health plan setting.

• Preferred: Familiarity with Medicare/Medicaid.

• Preferred: Experience in a call center or triage environment.

• Bilingual candidates are a plus.

🏝️ Benefits

• Bonus incentive plan based on both company and/or individual performance.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays.

• Personal holidays.

• Paid parental leave.

• Paid caregiver leave.

• Short-term disability.

• Long-term disability.

• Life insurance.

• Self-provided home internet service.

• Opportunity for remote work from home.

• Occasional travel to Humana offices for training or meetings.