Remote Utilization Management Manager

Humana Inc; Wisconsin; On-site; USD 95,000 - 131,000; Full time

Benefits offered by this job

Bonus eligible

Remote work

Job summary

Humana Inc. seeks a Utilization Management Manager in Wisconsin to lead a team performing medical necessity reviews, provider outreach, and prior authorization operations for Medicare and Medicaid services. You will drive quality, compliance, and continuous improvement while supporting providers and members.

The role requires an active WI RN license and 3+ years in utilization management with 2+ years in leadership. Remote work possible with travel for training or meetings.

Qualifications

• Bachelor's degree required.
• Active, unrestricted RN license in WI or compact state.
• 3+ years of utilization management experience.
• 2+ years of leadership experience managing clinical or operational teams.

Responsibilities

• Lead nurses and staff responsible for utilization management and prior authorization activities.
• Oversee medical necessity and level of care reviews for inpatient, outpatient, and behavioral health services.
• Ensure accurate, compliant authorization decisions aligning with regulatory requirements and policies.
• Monitor team productivity, quality, service levels and metrics.
• Educate providers on utilization management processes and guidelines.
• Lead process improvement and trend analysis projects to enhance quality and efficiency.
• Collaborate with cross-functional partners to address operational challenges and improve outcomes.
• Conduct team meetings, coaching, and performance discussions.

Skills

Utilization management

Nursing leadership

Provider outreach

Prior authorization

Excel macros

Education

Bachelor's degree

Tools

Excel

Job description

Humana Inc. seeks a Utilization Management Manager in Wisconsin to lead a team performing medical necessity reviews, provider outreach, and prior authorization operations for Medicare and Medicaid services. You will drive quality, compliance, and continuous improvement while supporting providers and members.

The role requires an active WI RN license and 3+ years in utilization management with 2+ years in leadership. Remote work possible with travel for training or meetings.