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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. The Utilization Management Behavioral Health Professional work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Key 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.

Use your skills to make an impact

Required Qualifications

Candidate must be one of the following:

• 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 BH experience

Candidate must also have 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: 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 required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay 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.

$65,000 - $88,600 per year

This 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

About Humana: 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. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at?Humana.com?and at?CenterWell.com.

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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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.