Utilization Management Manager

Become a part of our caring community

Join the WI Market Medicaid team at Humana in as a Utilization Management Manager. In this role you will lead a team responsible for medical necessity reviews, provider outreach, and prior authorization operations for Medicare and Medicaid services. Reporting to the Director, Health Services, you will drive quality, compliance, operational performance, and continuous improvement while supporting a positive experience for providers and members.

Job Responsibilities

• Lead nurses and support staff responsible for utilization management and prior authorization activities.
• Oversee medical necessity and level of care reviews for inpatient, outpatient, and behavioral health services using established clinical criteria and organizational guidelines.
• Ensure accurate and compliant authorization decisions that align with regulatory requirements and internal policies.
• Monitor team productivity, quality, service levels, and operational performance metrics.
• Provide guidance on complex clinical and operational issues and ensure appropriate escalation for additional review when needed.
• Educate providers on utilization management processes, medical necessity requirements, and prior authorization guidelines.
• Oversee provider outreach activities
• Ensure accurate entry, maintenance, and documentation of clinical information within medical management systems.
• Lead process improvement and trend analysis projects to enhance quality, consistency, efficiency, and compliance.
• Support the implementation, and administration of departmental policies, procedures, and workflow standards.
• Collaborate with cross-functional partners to address operational challenges and improve outcomes.
• Conduct team meetings, coaching sessions, and performance discussions to support employee engagement and development.
• Manage departmental resources and workflow to achieve organizational goals and service expectations.
• Promote a culture of accountability, quality, collaboration, and continuous improvement.

Required Qualifications

• Bachelor's degree
• Active, unrestricted Registered Nurse license in Wisconsin or a compact state
• 3+ years of utilization management experience
• 2+ years of leadership experience managing clinical or operational teams

Preferred Qualifications

• Live in the State of WI (or bordering state)
• Experience adjudicating or leading teams who adjudicate inpatient, outpatient, and behavioral health authorizations
• Experience with Medicare and Medicaid utilization review
• Experience leading process improvement or operational efficiency initiatives in a managed care environment

Additional Information

• Workstyle:

Remote- Home

• Typical Workdays/Hours:

Monday - Friday, 8:00am - 5:00pm Central Standard Time (CST)

• Experience writing complex macros for Excel

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 connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: 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

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