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The Utilization Management Behavioral Health Professional 2 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 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Role Responsibilities

Tasks include, but are not limited to:

70%: 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.

15%: 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.

10%: 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.

5%: Other tasks as assigned

Use your skills to make an impact

Required Qualifications

• 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, previously known as eQIP - Electronic Questionnaire for Investigation Processing)

• 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

Required Work Schedule

• Training is mandatory for the first 4 – 6 weeks from 8:00 AM – 5:00 PM Eastern time, Monday – Friday.

• Following training, must be able to work an 8-hour shift between the hours of 8:00 AM – 6:00 PM Eastern time, Monday - Friday.

• Overtime, weekends, and holidays may be required, based on business needs.

Preferred Qualifications

• Prior experience with the TRICARE Autism Care Demonstration

• Knowledge of and experience with applied behavior analysis and integrated care needs for those with autism

• Prior experience with Utilization Review, Utilization Management, Peer Reviews and/or Quality Management

• Knowledge of CPT codes that apply to ABA and/or experience with DMS-5 criteria

• Prior experience with outcome measure assessments to include PDDBI, Vineland, SRS and/or PSI-SIPA

• Experience with interpreting medical policy

• Direct or indirect military experience a plus

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.

• Satellite and Wireless Internet service is NOT allowed for this role

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

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

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.