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Humana · 1 day ago

Utilization Management Behavioral Health Professional 2

United States

Full-time

Remote

Mid Level

$65K/yr - $89K/yr

3+ years exp

Humana is committed to putting health first and is seeking a Utilization Management Behavioral Health Professional 2 to support the coordination and documentation of medical services. This role involves performing utilization management activities, collaborating with various departments, and ensuring compliance with policies and procedures.

Health CareHealth InsuranceInsuranceVenture Capital

No H1B

Security Clearance Required

U.S. Citizen Only

Responsibilities

Performing utilization management activities for assigned areas. Ensures full compliance with contract requirements, policies and procedures, and performance standards. Coordinates and implements contingency operations when needed

Perform accurate and timely initial and ongoing treatment reviews with documentation in MSR reflecting determination of appropriateness of level of care according to established Humana Government Business contractual requirements and guidelines

Uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, understanding moderately complex to complex issues and policies and procedures to determine the best and most appropriate treatment, care, or services for ACD participants

Review ABA TPs for policy compliance

Review pend queues for pended authorizations

Approve clinically necessary and appropriate ABA services

Review outcome measures to ensure compliance with ACD policy

Coordinates, conducts outreach, and communicates with providers, beneficiaries, or other parties to facilitate optimal care and treatment, when necessary, to educate and address clinical necessity concerns and ACD policy compliance requirements

Facilitating communication as needed between all departments within Humana Government Business and Humana corporate to resolve escalated issues and ensure the enterprise understand the function of the ACD team. Understanding and engaging in risk management procedures and analysis

Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas, as well as need for overtime, weekend, and holiday coverage when necessary to maintain contractual performance standards for referral and authorization processing

Collaborate with all Humana operations departments to operate and improve processes related to specialty team(s) effectiveness with the highest degree of attention to beneficiary and provider experience

Optimize staff productivity surrounding process management

Strategical look for interventions and methods to improve performance

Strategize with all leaders within the ACD team and Specialty team to make recommendations to the DHA or Humana Government Business to improve policy which may relate to better case management outcomes, improved utilization management, prevention or identification of fraud waste and abuse, and trend data

Other tasks as assigned

Qualification

BCBA CertificationApplied Behavioral AnalysisASDMicrosoft Office ProficiencyUtilization Management ExperienceCommunication SkillsCritical ThinkingProject Management

Required

Our Department of Defense Contract requires U.S. citizenship for this position

Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services)

HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico

BCBA (Board Certified Behavior Analyst) Certification

3 or more years of experience as a Board-Certified Behavior Analyst

3 or more years of applied behavioral analysis (ABA) with ASD (Autism Spectrum Disorder) experience

Proficiency in Microsoft Office programs specifically Word, Excel, and Outlook

Ability to handle multiple projects simultaneously and to prioritize appropriately