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Utilization Management Nurse Lead at Humana - ApplyBlast

Utilization Management Nurse Lead

Humana

3 months ago

3.6 on Glassdoor

Remote

Full Time

Senior

0 applicants

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About this role

The Utilization Management Nurse Lead interprets clinical data and policies to ensure optimal treatment and care for members while coordinating with providers and state agencies. This role involves analyzing utilization trends, supporting quality accreditation efforts, and advising executives on functional strategies to improve member outcomes. The position requires independent judgment to manage state reporting, oversee prior authorization teams, and ensure compliance with CMS and NCQA regulations.

Responsibilities

Interpret clinical data and policies to provide appropriate treatment
Coordinate with providers to facilitate optimal member care
Analyze utilization management trends impacting outcomes
Support quality efforts for HEDIS and NCQA accreditation
Manage state reporting and aggregate utilization metrics

Skills

Qualifications

Active RN License in MichiganBachelor's or Associate Degree in Nursing or Related Field5+ Years Clinical Experience in Utilization Management2+ Years Leadership ExperiencePreferred: Master's Degree in Nursing or Related Field

About Humana

humana.com

Headquarters

Louisville, Kentucky, United States

Company Size

10001+ employees

Founded

1961

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