Utilization Management Manager

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

📋 Description

• Lead nursing and support personnel responsible for utilization management and prior authorization tasks.

• Supervise reviews of medical necessity and level-of-care for inpatient, outpatient, and behavioral health services.

• Ensure that authorization decisions adhere to regulatory standards and internal policies.

• Track productivity, quality, service levels, and operational performance metrics.

• Facilitate the resolution and escalation of intricate clinical and operational challenges.

• Educate providers regarding utilization management, medical necessity, and prior authorization protocols.

• Oversee outreach initiatives directed at providers.

• Guarantee precise entry, upkeep, and documentation of clinical data within medical management systems.

• Lead initiatives for process improvement and trend analysis projects.

• Support departmental policies, procedures, and workflow standards.

• Collaborate with cross-functional teams to tackle operational difficulties and enhance outcomes.

• Conduct team meetings, coaching sessions, and performance evaluations.

• Manage departmental resources and workflow effectively.

• Foster accountability, quality, collaboration, and a culture of continuous improvement.

⛳️ Requirements

• Bachelor's degree.

• Current, unrestricted Registered Nurse license in Wisconsin or a compact state.

• At least 3 years of experience in utilization management.

• A minimum of 2 years in a leadership role managing clinical or operational teams.

• Proficient in writing complex macros for Excel.

• Availability from Monday to Friday, 8:00am to 5:00pm Central Standard Time.

• Minimum home internet speed of 25 Mbps download and 10 Mbps upload.

• A dedicated workspace that ensures no interruptions, safeguarding member PHI/HIPAA information.

🏝️ Benefits

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

• Comprehensive medical, dental, and vision benefits.

• 401(k) retirement savings plan.

• Paid time off.

• Company holidays.

• Personal holidays.

• Paid parental and caregiver leave.

• Short-term disability coverage.

• Long-term disability coverage.

• Life insurance.

• Arrangement for a dedicated home workspace.

• Opportunity for remote work.

• Occasional travel to Humana offices for training or meetings.