Location: Cincinnati, OH
Location Type: Cincinnati – Remote
Additional Location: AL; AK; AZ; AR; CA; CO; CT; DE; FL; GA; HI; ID; IL; IN; IA; KS; KY; LA; ME; MD; MA; MI; MN; MS; MO; MT; NE; NV; NH; NJ; NM; NY; NC; ND; OH; OK; OR; PA; RI; SC; SD; TN; TX; UT; VT; VA; WA; WV; WI; WY;
Job Description Summary
Humana Healthy Horizons in Ohio is seeking a Manager, Utilization Management (Behavioral Health) who will utilize clinical skills to support the coordination, documentation, and communication of behavioral health services and/or benefit administration determinations. The Manager, Utilization Management Behavioral Health applies a Person-Centered approach, works within specific guidelines and procedures; applies advanced technical knowledge and clinical criteria to solve moderately complex problems; receives assignments in the form of team and/or department goals and objectives and determines approach, resources, schedules and monitors success of appropriate team or department S.M.A.R.T goals
You will be part of a caring community at Humana.
When you meet us, you can tell we started as a hometown company. We’re proud of our Louisville roots and, as we’ve grown, that community feeling has spread across all 50 states and Puerto Rico. No matter where you are—whether you’re working from home, from the field, from our offices, or from somewhere in between—you’ll feel welcome here. We’re a caring community made of close-knit teams, cross-country friendships, and inclusive resource groups, all gathered around one big table where everyone’s voice is heard and respected. Community is a verb here. It’s up to each of us to care for it and maintain it. Because the relationships we form will help us deliver better health outcomes for the people we so proudly serve.
Are you Caring, Curious and Committed? If so, apply today!
Essential Functions and Responsibilities
- Supervise utilization management personnel and oversee all utilization management functions, including inpatient admissions, concurrent review, prior authorization and referrals to care management.
- Oversee, monitor, orient and train staff in the use of standard utilization management criteria including ASAM.
- Lead development of utilization management policies and procedures to ensure compliance with state and federal requirements and incorporate industry best practices.
- Collaborate with internal departments, providers, and community partners to support the delivery of high-quality utilization management services, including introducing innovative approaches to utilization management.
- Monitor and maintain staffing levels to meet care and service quality objectives
- Conduct timely evaluations of direct reports and provide regular opportunities for professional development.
- Influence and assist corporate leadership in strategic planning to improve effectiveness of behavioral health utilization management programs.
- Collect and analyze performance reports on utilization management functions to monitor adherence with benchmarks, identify opportunities for process improvement, and develop recommendations to leadership.
- Conducts briefings and area meetings; maintains frequent contact with other managers across the department and the company.
This is a remote position
- Licensed Registered Behavioral Health Professional (LSW, LISW, LPC, LPCC or LPCC- S) or licensed Registered Nurse (RN), in the state of Ohio with no disciplinary action.
- Previous experience in utilization management.
- Two (2) years of leadership experience.
- Two (2) or more years of clinical experience working with the behavioral health populations preferably in an acute care, skilled or rehabilitation clinical setting.
- Knowledge of ASAM, Interqual and/or Milliman (MCG) criteria.
- Comprehensive knowledge of Microsoft Office applications including Word, Excel, and Outlook.
- Ability to work independently under general instructions and with a team.
- Must have a separate room with a locked door that can be used as a home office, to ensure you have absolute and continuous privacy while you work.
- Bachelor’s degree or Master’s degree in nursing, psychology, health services, social work, healthcare administration, or business administration.
- Experience working with Medicaid and/or health plan behavioral health Utilization Management.
- Possess subject matter expertise in review of behavioral health inpatient admission and concurrent reviews requests.
- Experience managing behavioral health utilization management staff.
- Experience serving Medicaid, TANF, and/or CHIP populations.
- Travel: Up to 25% in-state travel
- Typical Work Days/Hours: Monday – Friday; 8:00am – 5:00pm with potential rotating on-call schedule.
- Direct Reports: up to 15 associates.
Your growth is what drives Humana forward.
- When you get here, the journey is just beginning. Our leaders are committed to understanding what you need to grow. Because we don’t grow without you.
- This is a place where our nurses influence the C-suite.
- Where software engineers change lives.
- Where every associate can build a professional path where they learn and thrive.
- Through our commitments to wellbeing and work-life balance, we support each associate’s personal health, purpose, work style, sense of belonging, and security.
- Because finding new ways to put health first—for our members and patients and our associates alike—is what we do.
Work at Home Guidance
To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
- At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
- Satellite, cellular and microwave connection can be used only if approved by leadership
- Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
- Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
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