• Job Description

  Req#: R-378317

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

  The Manager of National Medicaid Clinical Operations is responsible for managing the day-to-day operations of nonclinical staff involved in the prior authorization process. This role ensures that all prior authorization activities are conducted efficiently and in compliance with federal and state regulations and accreditation bodies. The Manager will report directly to the Associate Director and play a key role in promoting quality improvements, fostering a collaborative work environment, and ensuring that service standards are met.

  Key Responsibilities:

  Staff Management:

  • Oversee the hiring, training, and development of clinical and nonclinical staff.

  • Conduct regular performance evaluations and provide coaching and mentoring to staff .

  • Ensure staff are knowledgeable about Medicaid policies and procedures .

  Operational Oversight:

  • Manage the day-to-day operations of clinical and nonclinical services .

  • Develop and implement policies and procedures to ensure efficient and effective operations .

  Compliance and Quality Assurance :

  • Ensure compliance with all regulatory and accreditation requirements.

  • I mplement quality assurance measures to maintain high standards of service .

  • Conduct regular audits and reviews to ensure accuracy and consistency in prior authorization review processes.

  Coordination and Collaboration :

  • Promote intradepartmental and cross-market coordination to ensure cohesive operations .

  • Foster collaboration between clinical and nonclinical teams to streamline processes and improve outcomes .

  • Liaise with healthcare providers, payers, and other stakeholders to address operational issues .

  Data and Trend Analysis:

  • Conduct data analysis to identify trends and inform decision-making .

  • Use data-driven insights to optimize workflows and improve service delivery .

  Quality Improvements:

  • Develop and implement quality improvement initiatives to enhance the efficiency and effectiveness of prior authorization.

  • Monitor performance metrics and implement strategies to achieve continuous quality improvement.

  Strategic Planning:

  • Assist in e stablish ing long-range goals, objectives, and plans that align with State-specific and Enterprise Medicaid strategic priorities.

  • Adapt plans to meet the evolving needs of members, providers, and regulatory partners.

  
  Use your skills to make an impact
  

  Required Qualifications

  • Active Registered Nurse, RN, license in a state that participates in the enhance licensure, (eNLC) without disciplinary action.

  • Minimum 2 years of experience in prior authorization, utilization management or related fields.

  • Minimum 2 years of experience as a Team Lead, Subject Matter Expert, (SME), Project Leadership, Charge Nurse

  • Experience with Medicaid policies and procedures.

  • Knowledge of payer policies, insurance companies and government health programs.

  • Ability to work collaboratively with diverse teams and stakeholders.

  Preferred Qualifications

  • Bachelor’s Degree.

  • At least 1 year in a leadership role overseeing clinical teams.

  • Familiarity with both physical and behavioral health services.

  • Experience in process improvement- Six Sigma/Lean Concepts.

  • Experience leading multi-state clinical teams.

  Additional Information

  Workstyle: Remote work at home
  Location: Prefer South Carolina

  Schedule: Monday - Friday 8:00 AM to 5:00 PM Eastern and on call duties weekends on a rotating basis

  Travel: Travel as needed to market meetings

  Work at Home Guidance 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 recommended; 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.

  Interview Format As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making. If you are selected to move forward from your application prescreen, you will receive an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. (Please be sure to check your spam or junk folders often to ensure communication isn’t missed) If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes. If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

  SSN Alert Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide their social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.

  Section 1121 of the Louisiana Code of Governmental Ethics states that current or former agency heads or elected officials, board or commission members or public employees of the Louisiana Health Department (LDH) who work directly with LDH’s Medicaid Division cannot be considered for this opportunity. A separation of two (2) or more years from LDH is required for consideration. For more information please visit: Louisiana Board of Ethics (la.gov)

  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.

  
  

  $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.

  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.

• About the company

  Humana looks at every facet of your life and works with you to create a path to health that fits your unique needs

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