Utilization Management - Behavioral Health - Inpatient

Humana • Work at Home - Illinois, SC

2d • $65,000 - $88,600 • Remote

About The Position

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.

Requirements

• 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
• 1+ year of post-degree clinical experience in private practice or other patient care
• Self-provided internet service with at least a download speed of 25 Mbps and an upload speed of 10 Mbps
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Nice To Haves

• 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

Responsibilities

• 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
• 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
• 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
• 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
• 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

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level