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.

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 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, and certifications.

$65,000 - $88,600 per year. This job is eligible for a bonus incentive plan based upon 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.