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Humana Utilization Management Process Improvement Lead in San Antonio, Texas

Description

The Process Improvement Lead analyzes, and measures the effectiveness of existing business processes and develops sustainable, repeatable and quantifiable business process improvements. The Process Improvement Lead works on problems of diverse scope and complexity ranging from moderate to substantial.

Responsibilities

The Utilization Management (UM) Process Improvement Lead analyzes and measures the effectiveness of existing business processes and develops sustainable, repeatable and quantifiable business process improvements that focus on enhanced safety, increased productivity and reduced cost. The Process Improvement Lead works on problems of diverse scope and complexity ranging from moderate to substantial, and determines how new information technologies can support improved efficiency in UM business processes.

Responsibilities

The UM Process Improvement Lead will be primarily responsible for leading projects and user groups for Medical Management IT systems changes and enhancements, maintaining URAC compliance and accreditation, and collaborating across the organization to ensure alignment between medical management, claims processing, claims cost containment and others. Must be a self-starter, work independently with minimal direction, and possess the ability to prioritize multiple tasks effectively.

KEY ACCOUNTABILITIES

35% Lead and manage Medical Management Systems user group, develop project requirements and lead implementation, complete user end testing, and approve system changes.

25% Monitor UM process and system changes to ensure compliance with URAC standards, lead the submission of URAC reaccreditation documentation, and prepare associates for onsite URAC reaccreditation review.

20% Implement routine maintenance of UM systems to include collaboration with IT to load medical coding updates, completion of table updates, review of TRICARE policy changes and implementation of required system updates.

10% Collaborate with Claims Oversight, IT, and various other departments to ensure alignment of data elements and processes, and ensure appropriate implementation.

10% Perform other duties as required

Required Qualifications

  • Our Department of Defense contract requires U.S. Citizenship

  • Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)

  • Bachelor's degree in Nursing, Healthcare Management or related field

  • 3 or more years of experience in utilization management processes, including medical necessity criteria and UM systems

  • 2 or more years of project leadership experience

  • Experience with URAC, to include leading re-accreditation activities

  • Strong analytical and problem solving skills

  • Ability to manage multiple priorities and work collaboratively across departments

  • Excellent written and verbal communication skills

  • Experience in identifying and effectively communicating actionable insights from data analysis

Preferred Qualifications

  • Current RN license in state of employment

Scheduled Weekly Hours

40

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