Utilization Management Manager

Humana Inc; Northern (KY); Hybrid; USD 95,000 - 131,000; Full time

Benefits offered by this job

Bonus eligibility

Remote work from home

Job summary

Humana Inc. is seeking an Utilization Management Manager to lead a remote Wisconsin-based team responsible for medical necessity reviews and prior authorizations for Medicare and Medicaid services.

You will drive quality, compliance, and operational performance while supporting providers and members. The role requires an RN license (WI or compact), 3+ years in utilization management, and 2+ years of leadership experience.

Qualifications

• Active, unrestricted RN license in Wisconsin or a compact state is required.
• Minimum 3+ years in utilization management with leadership experience.
• Bachelor's degree and strong analytical/communication skills are required.

Responsibilities

• Lead nurses and support staff in utilization management and prior authorization.
• Oversee medical necessity and level-of-care reviews across services.
• Ensure compliant, accurate authorization decisions per regulations.
• Monitor team productivity, quality, and service levels with metrics.
• Educate providers on processes and guidelines; drive process improvement.
• Manage resources and collaborate with cross-functional partners.

Skills

Active RN license (WI or compact)

Utilization management experience

Leadership experience

Excel macros / advanced Excel

Education

Bachelor's degree

Tools

Microsoft Excel

Job description

## Utilization Management ManagerApply: Remote Wisconsin: Full time: Posted Yesterday: R-429310# **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.# **Use your skills to make an impact**### 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 ExcelWork 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.**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 yearThis 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.# **About us**About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.