Utilization Management - Behavioral Health - Outpatient

Become a part of our caring community. The Utilization Management Behavioral Health Professional utilizes behavioral health knowledge and skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.

Responsibilities

• 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.
• 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.
• 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.
• 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.
• 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

• Licensed Masters Clinical Social Worker (LCSW), Licensed Masters Social Worker (LMSW-ACP), Licensed Professional Counselor (LPC), Psychologist (PhD), or 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.

Qualifications

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: at minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps; wireless, wired cable, or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
• While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Schedule

Scheduled weekly hours: 40

Pay

The pay range is $65,000 - $88,600 per year. This job 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.

About Us

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.