Associate Director, Health Services Nursing
Anderson, Anderson County, South Carolina, 29621, USA
Listed on 2026-08-04
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Healthcare
Healthcare Management
Become a part of our caring community
The Associate Director, Health Services Nursing is responsible for driving excellence in care management (CM) and utilization management inpatient (UM) clinical operations through process improvement initiatives, process development, market enablement, targeted process audits, and training facilitation. The Associate Director, Health Services Nursing, collaborates across clinical and operational teams to advance best practices, support strategic growth, optimize performance and advance best practices.
The Associate Director, Health Services Nursing, leads all efforts in finding and executing creative ways to remove friction from the system for both our members and provider partners at every opportunity.
Oversee the assessment and evaluation of members' needs and requirements to achieve and maintain optimal wellness by guiding members/families toward and facilitate interaction with resources appropriate for the care and well-being of members.
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 care management and utilization management team members ensuring that the service provided meets or exceeds clinical and procedural National Committee for Quality Assurance (NCQA) and state standards.
Ensure adoption and consistent application of appropriate medical necessity criteria.
Monitor and evaluate performance metrics and outcomes to ensure the effectiveness and quality of care management activities
Oversee care management and utilization management functions and assure that decisions are made in a timely and consistent manner based on clinical criteria and contract requirements 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 NCQA, Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.
Participate in audit preparation and response, including EQRO and other regulatory reviews.
Develop team members and create department process flows.
Lead multiple managers or highly specialized professional associates.
Facilitate cross-departmental collaboration to optimize member outcomes and operational efficiencies.
Decisions are typically related to identifying and resolving complex technical and operational problems within department(s).
Required Qualifications
An active, unrestricted Registered Nurse (RN) license in the State of South Carolina with no disciplinary actions.
Bachelor's degree in nursing (BSN) or a related healthcare field.
Three (3) or more years of clinical leadership experience in utilization management.
Three (3) or more yearsof care management leadership experience.
Three (3) or more yearsof Medicaid-related experience.
Familiarity with Inter Qual, MCG, and/or ASAM criteria.
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.
South Carolina residency.
Bachelor's degree in nursing (BSN), Public Health, Health Administration, Health Policy, or Business.
Knowledge of Humana's internal policies, procedures, and systems.
Workstyle: This is a remote position.
Travel: Up to 50% to support team engagement and strategic planning initiatives in Humana's Columbia, SC office location.
Direct Reports: Up to 5 associates.
Work at Home Requirements:
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL…
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