Utilization Management Behavorial Health Professional

Virginia, 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 possess an active unrestricted registered nurse license in Virginia or a multi-state license in an enhanced compact licensure (eNLC) state, or an active unrestricted LCSW, LPC, LMFT, or LCP license to practice as a health professional in Virginia. A minimum of one year of post-degree clinical experience in private practice or another patient care setting and one year of managed care experience are required. Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) and the ability to navigate multiple systems are essential, along with strong oral, written, and interpersonal communication, problem-solving, and facilitation skills. Candidates must be able to work independently under general instructions and as part of a team. For remote work, a dedicated, interruption-free workspace and internet service with at least 25 Mbps download and 10 Mbps upload speeds are necessary.

Responsibilities

The Utilization Management Behavioral Health Professional utilizes 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 optimal treatment and care. Responsibilities include coordinating and communicating with providers, members, and other parties to facilitate care, making independent decisions regarding work methods, and following established guidelines. Experience with utilization review, behavioral change, health promotion, coaching, wellness, and knowledge of community health and social service agencies are preferred.

Skills

Behavioral Health

Clinical Knowledge

Microsoft Office Suite

Managed Care

Critical Thinking

Communication

Coordination of Care

Benefit Administration

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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