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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

We are seeking a typical Monday-Friday schedule, as well as weekend coverage (i.e. Wed-Sun, Thu-Mon or Fri-Tue type schedule). This will be discussed during interview.

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.