Utilization Management - Behavioral Health - Outpatient

Join our caring community as a Utilization Management Behavioral Health Professional, utilizing behavioral health knowledge and skills to support coordination, documentation, and communication of medical services and benefit administration determinations. Assignments are varied and frequently require interpretation and independent decision-making.

Responsibilities

• Clinical Review: Conduct comprehensive clinical reviews of prior authorization requests for behavioral health services to determine medical necessity. Apply advanced evidence-based clinical guidelines in review decisions. Ensure compliance with accreditation, state, and federal regulations.
• Communication and Coordination:
  • Communicate with healthcare providers to obtain necessary clinical information and clarify requests.
  • Coordinate with medical directors and interdisciplinary teams to support decision-making.
  • Serve as a liaison between clinicians, internal departments, and providers.
• Documentation and Reporting:
  • Document all review findings and decisions in the clinical documentation system.
  • Ensure timely and accurate documentation of prior authorization determinations.
  • Support reporting initiatives and provide data for performance improvement projects.
• Quality Assurance:
  • Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions.
  • Participate in and review audit findings to maintain high standards of service.
  • Identify process improvement opportunities and contribute to performance improvement projects.
• Education and Training:
  • Educate providers and staff on prior authorization policies, criteria, and review processes.
  • Provide mentorship and feedback to nonclinical staff to enhance workflow efficiency.
  • Stay current with clinical best practices and regulatory changes.

Requirements

• Must hold one of the following licenses:
  • Licensed Masters Clinical Social Worker (LCSW)
  • Licensed Masters Social Worker (LMSW-ACP)
  • Licensed Professional Counselor (LPC)
  • Psychologist (PhD)
  • Registered Nurse, licensed in IL, with 3 years of behavioral health experience
• 1+ year of post-degree clinical experience in private practice or other patient care settings.

Preferred Qualifications

• Experience with utilization review.
• Experience with behavioral change, health promotion, coaching, and wellness.
• Certification in Case Management (CCM).
• Experience with Medicaid and Medicare policies and procedures.
• Experience working with the older adult population.
• Knowledge of payer policies, insurance companies, and government health programs.
• Knowledge of community health and social service agencies and additional community resources.
• Bilingual (English/Spanish); speaking, reading, writing, interpreting, and explaining documents in Spanish.

Work at Home Requirements

• Self-provided internet service must meet the following criteria:
  • Minimum download speed of 25 Mbps and upload speed of 10 Mbps.
  • Wireless, wired cable, or DSL connection suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
• Occasional travel to Humana's offices for training or meetings may be required.

Schedule

Scheduled weekly hours: 40 (full time).

Pay

The pay range reflects a good faith estimate of starting base pay for full-time employment (40 hours per week) at the time of posting. The range may vary based on geographic location, and individual pay is determined by demonstrated job-related skills, knowledge, experience, education, and certifications.

$65,000 - $88,600 per year. This role is eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

• 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.
• Additional opportunities designed to support whole-person well-being.

About Us

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through Humana insurance services and CenterWell healthcare services, we make it easier for millions of people to achieve their best health by delivering care and services when they need it.