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The Medicaid MHPAEA (Mental Health Parity and Addiction Equity Act) Senior Risk Professional is responsible for overseeing and managing risks associated with Medicaid utilization management (UM) programs to ensure compliance with MHPAEA regulations. This role involves maintaining the library of regulatory requirements, developing, and implementing risk management strategies, conducting risk assessments, and collaborating with various stakeholders to ensure audit readiness.

Humana is seeking a seasoned expert in Utilization Management to join the UM Risk Management team and help support Medicaid MHPAEA (Mental Health Parity and Addiction Equity Act) compliance and risk oversight. The UM Risk team serves as the “1st line of defense” for Humana’s Clinical Operations segment, delivering a comprehensive operational risk management program with an eye toward prevention, timely detection, and swift remediation of risks and issues. The team focuses on identifying risks and issues, driving implementations and other special projects to promote operational excellence, consulting with business operators on key initiatives and challenges, infusing a compliance culture throughout the organization, and ensuring external audit readiness. The Mental Health Parity Senior Professional will analyze MHPAEA requirements, assess operational implementation, create and maintain supporting documentation, manage information requests related to MHPAEA compliance, support MHPAEA audit readiness, and assist with remediation of issues identified.

Key functions of this role include:

• Serve as a Subject Matter Expert on MHPAEA risk and requirements at an enterprise-level, actively partnering with other Humana oversight groups including Regulatory Compliance, Legal, Internal Audit, and Government Affairs and providing guidance and support as needed.
• Develop and implement comprehensive risk management plans to proactively identify and mitigate identified risks. Prepare detailed risk reports and present findings to senior management.
• Develop and maintain a comprehensive MHPAEA compliance program for Clinical NQTLs. Evaluate existing processes/factors/evidentiary standards against parity requirements using policies, procedures, data analysis, and case-level auditing.
• Stay apprised of existing, new, or emerging regulatory guidance related to MHPAEA; work closely with operational business units to ensure understanding of guidance and timely implementation. Ensure Medicaid programs adhere to MHPAEA requirements and other relevant federal and state regulations.
• Represent Humana Clinical Operations on all MHPAEA-related external audits and requests - inclusive of audit timeline management, documentation and data collection/review, audit response development, and issue/gap resolution. This role may interface with external regulators on occasion.
• Work with business partners to develop comprehensive remediation plans for issues identified. Support the implementation of remediation plans and validation of effectiveness prior to closure. Promote a culture of compliant and continuous improvement within the organization.
• Conduct regular risk assessments to identify potential areas of non-compliance.

Use your skills to make an impact
 

Required Qualifications

• Bachelor’s degree or equivalent experience
• 3+ years of experience with Utilization Management, Care Management or Case Management
• 2+ years of experience with healthcare or insurance regulations
• Successful record of building and maintaining positive cross-functional relationships and driving shared accountability
• Ability to work independently and effectively allocate time
• Strong analytical and problem-solving abilities
• Attention to detail and proactive approach to identifying and mitigating risks
• Demonstrated ability to articulate ideas effectively in both written and oral forms

Preferred Qualifications

• Experience with Mental Health Parity and Addiction Equity Act (MHPAEA) regulations and/or oversight
• Bachelor’s degree or higher in healthcare, risk management, or a related field.
• Experience and/or certifications in risk management, compliance, or a related role within the healthcare sector
• Experience with Medicaid programs
• Experience analyzing data sets for purposes of risk identification

Additional Information

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 u