Become a part of our caring community and help us put health first
 

Are you looking to join a team where you can be a part of our important mission of supporting the TRICARE healthcare program for our nation's military and use your data skills? Humana Government Business is a top 10 Department of Defense contractor, with a long history in the TRICARE business and has been awarded the T-5 East Region, the next generation of military health contracts.

The Director, Referrals process referrals from Military Treatment Facilities (MTFs) and civilian providers. The Director, Referrals requires an in-depth understanding of how organization capabilities interrelate across the function or segment.

The Director, Referrals has oversight for team handling data entry into medical management system, assigning an appropriate provider, reviewing for benefits, and/or medical necessity as required or pending to a nurse or supervisor who can complete or request additional information. Recognizes a sensitive diagnoses and/or referral requiring Case Management, and pend to appropriate point of contact for review. Understands TRICARE benefits/limitations and Humana Military referral processes, MOUs with MTFs, and referral and UM policies. Answers questions or contacts MTFs and/or civilian providers to obtain additional information that may be required to complete referral etc. Requires assigning appropriate ICD10 code to referral as well as appropriate CPT Code. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy.

Key Accountabilities

• Ensures associates comply with DHA and HGB policy. Provide reporting required by contract. Serves as the point of contact (POC) for the DHA Referrals SME and for all referral issues in the East TRICARE region.

• Integrate clinical elements of Cost of Care programs

• Develop and direct clinical field internal quality reviews pertaining to Case Management and Utilization Management, which contribute to Care Management, and maximize efficiency and effectiveness of health safety for beneficiaries.

• Provide efficient integrative management to meet initiatives of HGB.

• Identify variances in reviewer activity and UM trends, and direct corrective intervention.

Use your skills to make an impact
 

Required Qualifications

• Our Department of Defense contract requires U.S. Citizenship

• Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)

• HGB is not authorized to do work in Puerto Rico per our government contract.  We are not able to hire candidates that are currently living in Puerto Rico.

• Professional Registered Nurse with valid license

• Bachelor’s degree in health-related field

• 5 years of management experience

• 5 years of RN Clinical experience

• 5 years of broad healthcare delivery experience

Preferred Qualifications

• Professional certification in case management, or quality management (such as Certification in Managed Care Nursing (CMCN), Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM)

• Military healthcare experience

• TRICARE experience

• Graduate degree in business or related field

Work at Home Requirements

To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home 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, cellular and microwave connection can be used only if approved by leadership

• 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

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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 high