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The Director, Health Services utilizes clinical skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Director, Health Services requires an in-depth understanding of how organization capabilities interrelate across the function or segment.The Director, Health Services, uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s), and could lead multiple managers or highly specialized professional associates.
The role requires experience caring for patients with complex medical and social needs and an understanding of how to provide care more efficiently and effectively with an interdisciplinary team. We are looking for individuals who are passionate about transforming our care system for patients who need it most and are driven by doing well by doing what’s right. This candidate must be an insightful risk-taker willing to thoughtfully disrupt the status quo and excited to work in a rapidly evolving start-up environment.
The role of Director, Health Services will focus on the following areas:
Serve as a thought leader in designing and implementing the interdisciplinary care team
Develop and monitor all clinical protocols, either independently or in collaboration with other interdisciplinary care team members as relevant, for the care team to use for both in person and virtual (both tech-enabled and telephonic) care management, chronic disease management and care at points of transition
Determine state dependent requirements and modify work of the care team as necessary to ensure compliance with all local policies and practices
Oversees the hiring and management of a team in the market that provides direct member care
Developing and implementing Clinical Prior Authorization policies, processes, detailed workflows, and leading the Utilization Management team.
Hiring and directly leading a team of Utilization Management nurses, clinicians and support staff responsible for reviewing and processing clinical authorizations and clinical claims reviews
Assure compliance with state timeframes for turnaround times on authorization requests and delivery of Utilization Management services
Use your skills to make an impact
Required Qualifications
- Active Registered Nurse (RN) license, or Licensed Social Worker (LSW) licensed in the state of South Carolina
- 3+ years of leadership experience
- 7+ years working in the areas of Utilization Management and/or Case Management
- 2+ years of Medicaid Managed Care experience
- Recent working knowledge and familiarity with Milliman Care Guidelines medical criteria and administering clinical practice guidelines
- Demonstrated experience and recommendations from peers as a customer-focused, team player, with collaborative approach to leading
- Strong understanding of clinical data and reporting
- Intermediate to advance computer skills and experience with Microsoft Office specifically Power Point, Word, Excel and Outlook
- MUST RESIDE IN SOUTH CAROLINA
Preferred Qualifications
- Master's Degree
- Management of physical and behavioral health staff
- 2+ years developing collaborative partnerships with enterprise cross-functional teams
- Experience working with Medicaid and/or Medicare populations
- Medicaid market implementation experience
- Previous experience with electronic case note documentation and experience with documenting in multiple computer applications/systems
- Certified Professional in Health Care Quality (CPHQ)
- Certified in Health Care Quality and Management (CHCQM)
Additional Information
- This is a remote position in South Carolina
- Travel requirement up to 40% within the state of South Carolina
- This role is a part of Humana’s Driver Safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.
Work at Home Criteria
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.
- 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 for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Scheduled Weekly Hours
40Pay 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.$123,800 - $170,400 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, 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 because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
