Utilization Management Behavioral Health Professional

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

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.

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

• 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)
• 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.
• 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

• 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.

• Prior…