LTSS UM Nurse Manager

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

The LTSS UM Nurse Manager will report to the Associate Director of Care Management. You will use clinical nursing skills to support the coordination, documentation and communication of medical services and benefit administration determinations. The Manager, Utilization Management Nursing operates within established guidelines, uses advanced technical expertise to address moderately complex issues, and independently determines methods, resources, schedules, and goals based on assigned goals.

• Use clinical knowledge toward interpreting criteria and procedures to provide the best treatment, care, or services for Members.
• Responsible for leadership and oversight of the physical health Utilization Management staff in daily operations.
• Hire, coach, counsel and evaluate performance of direct reports.
• Implement and maintain processes that are compliant with the Michigan Department of Health and Human Services (MDHHS) and National Committee for Quality Assurance (NCQA) guidelines.
• Work with UM leadership to reduce inefficiencies and provide solutions to improve clinical outcomes.
• Collect and analyze data to guide operational metrics and associate performance.
• Coordinate and communicate with Providers, Members, or other parties to facilitate care and treatment.
• Make decisions that are typically related to resources, approach, and tactical operations for projects involving own departmental area.
• Facilitate cross-departmental collaboration and conduct briefings and area meetings; maintain frequent contact with other managers across departments.

• Bachelor's Degree
• 2 or more years of management experience
• Licensed Registered Nurse (RN) in Michigan with no disciplinary action
• Previous experience in utilization management.
• Lead interdisciplinary teams, encouraging a collaborative environment that promotes accountability, professional growth, and high-quality service delivery within long-term services and supports (LTSS).
• 1+ years experience within long-term services and supports (LTSS) programs, including knowledge of Medicaid waivers, care coordination, and eligibility requirements.
• Progressive clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
• Demonstrated ability to work independently under general instructions and collaboratively within interdisciplinary care teams, including social workers, nurses, and allied health professionals.

• Health Plan experience
• Prior Medicare / Medicaid experience
• Prior clinical experience preferably in LTSS settings such as home health, hospice, nursing facilities, or adult day services, focusing on care for individuals with disabilities, aging adults, or those requiring extended support.
• Call center or triage experience
• Bilingual

You will be fully remote residing in the state of MI or within 40 miles from MI.

We will use Hire Vue technology for the initial step in the interview screening process. This includes a brief text assessment and video screen. We will notify you either way if the hiring leader selects you for the live interviews.

While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

40

$94,900 - $130,500 per year

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

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.

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