[Remote] Utilization Management - Behavioral Health at Humana

Kentucky, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must reside in Kentucky or a bordering county in Ohio, Indiana, Illinois, Missouri, Tennessee, Virginia, or West Virginia. A minimum of 3 years of post-degree clinical experience in private practice or other healthcare settings is required. Applicants must be a Registered Nurse licensed in Kentucky without restrictions, a Licensed Masters Clinical Social Worker (LCSW), a Licensed Marriage and Family Therapist (LMFT), a Licensed Professional Counselor (LPC), or a Psychologist (PhD). Experience with the utilization review process, outpatient behavioral health, substance use disorders, behavioral change, health promotion, coaching, wellness, and the older adult population is preferred. Bilingual skills in Spanish are also a plus.

Responsibilities

The Utilization Management Behavioral Health Professional 2 will use behavioral health knowledge to coordinate, document, and communicate medical services and benefit administration determinations. This role involves interpreting criteria, policies, and procedures to ensure members receive appropriate treatment and care. Responsibilities include coordinating and communicating with providers, members, and other parties to facilitate optimal care. The professional will also make decisions regarding work methods, follow established guidelines, and occasionally travel to the corporate office in Louisville, Kentucky, as needed. The role requires understanding department, segment, and organizational strategy.

Skills

Behavioral Health

Clinical Knowledge

Coordination

Documentation

Communication

Critical Thinking

Medical Services

Benefit Administration

Registered Nurse

LCSW

LMFT

Licensed Professional Counselor

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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