Associate Director, Health Services - Remote Eligible

Associate Director, Health Services

The Associate Director, Health Services serves as the strategic leader for utilization management, population health, care coordination and case management as well as serving as a key thought partner in building out clinical capabilities.

The Associate Director, Health Services:

• 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.
• Requires deep expertise in utilization management as well as rethinking the approach to providing members with the care that they need.
• Oversee the assessment and evaluation of members' needs and requirements to achieve and/or 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 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

• Bachelor's degree in nursing, public health, health administration, health policy or business.
• Knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards.
• 3+ years of previous clinical leadership experience in utilization management, including InterQual, MCG, and/or ASAM criteria.
• 3+ years of care management leadership experience.
• 3+ years of Medicaid related experience.
• Comprehensive knowledge of Microsoft Office applications including PowerPoint Word, Excel, and Outlook.

Preferred Qualifications

• Unrestricted Registered Nurse (RN) license in the state of South Carolina with no disciplinary action.
• Knowledge of Humana's internal policies, procedures and systems.

Additional Information

• Workstyle: Remote Work at Home
• Location: South Carolina Preferred
• Travel: up to 50%

WAH Internet Statement

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. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. 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.

Scheduled Weekly Hours 40

Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $104,000 - $143,000 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits 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.

About Us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.