Associate Director, Utilization Management (Behavioral Health) - VA Medicaid

at  Humana

BECOME A PART OF OUR CARING COMMUNITY AND HELP US PUT HEALTH FIRST

Humana Healthy Horizons in Virginia is seeking an Associate Director, Utilization Management Behavioral Health who will use their clinical knowledge, communication skills, and independent critical thinking skills to interpret criteria, policies, and procedures that provide the best and most appropriate behavioral health treatment, care, or services for Members. The individual coordinates and communicates with Providers, Members, or other parties to facilitate optimal care and treatment.

• Serves as a liaison between Humana and the Commonwealth regarding prior authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.
• Coordinates with the Clinical Leadership team to ensure all utilization reviews comply with Medicaid Contract terms.
• Provides supervision and daily guidance to prior authorization associates ensuring that the service provided meets or exceeds clinical, procedural, and the Virginia Department of Medical Assistance (DMAS) standards.
• Ensures adoption and consistent application of appropriate medical necessity criteria.
• Oversee the PUMS Program to ensure that Members are accessing and utilizing services in an appropriate manner in accordance with all applicable rule and regulations.
• Monitors, analyzes, and implements appropriate interventions based on utilization data, including identifying and correcting over- or under-utilization of services.
• Oversees prior authorization functions and ensures that decisions are made in a timely and consistent manner based on clinical criteria, and meets timeliness standards to ensure appropriate Notice of Action is followed including collaboration with the Medical Director to ensure reason for denial, reduction, or termination is specific and clear.
• Develops and implements departmental policies and procedures in accordance with contract changes or updates.
• Maintains compliance with DMAS, NCQA, Department of Health and Human Services (DHHS), and the Centers for Medicare & Medicaid Services (CMS) guidelines and contractual requirements.

REQUIRED QUALIFICATIONS

• A Virginia unrestricted licensed registered nurse (RN) with a BSN, Bachelor’s Healthcare Administration or Business Administration OR a Virginia unrestricted Behavioral Health clinician license such as a Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT).
• Minimum five (5) years of previous clinical experience in utilization management.
• Minimum three (3) years of leadership experience.
• Comprehensive knowledge of Microsoft Office applications including PowerPoint, Word, Excel, and Outlook.
• Knowledge of Medicaid regulatory requirements and National Committee for Quality Assurance (NCQA) standards.

PREFERRED QUALIFICATIONS

• Master’s degree in a behavioral health related field such as social work, counseling, and/or psychology, from an accredited university preferred.

DESCRIPTION OF BENEFITS

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

ABOUT US

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Please refer the Job description for details