• Job Description

  Req#: R-331850

  Become a part of our caring community and help us put health first
  

  This is a non-exempt position with responsibility for utilization management and clinical decision-making as outlined in the Autism Care Demonstration (ACD) defined in the TRICARE Operations Manual Chapter 18, section 4. The UM Senior Care Manager conducts clinical necessity reviews for requested ABA services when approving all treatment plans, initial authorization requests, and every six-month reauthorization thereafter. Utilizes evidence based criteria to assist in guiding clinical decisions, reviewing for appropriate care and setting, following guidelines and policies to approve services or forward requests to necessary stakeholders as required, and enters and maintains pertinent clinical information in various medical management systems. In addition, utilizes knowledge, communication skills and critical thinking skills to support the coordination and documentation of medical services and/or benefit administration determinations. The work assignments are varied and may involve complex issues where the analysis of situations and clinical documentation requires an in-depth evaluation of variable factors.

  KEY ACCOUNTABILITIES

  Tasks include, but are not limited to:

  Performing utilization management activities for assigned areas. Ensures full compliance with contract requirements, policies and procedures, and performance standards.

  • Performs accurate & timely initial and ongoing treatment reviews with documentation in referral and authorization system reflecting determination of appropriateness of level of care according to established Humana Government Business contractual requirements and guidelines.

  • Uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, understanding complex issues and policies and procedures to determine the best and most appropriate services for ACD participants.

    • Review ABA treatment plans for policy compliance

    • Review pend queues for pended authorization requests

    • Approve clinically necessary and appropriate ABA services

    • Review outcome measures to ensure compliance with ACD policy

    • Coordinates, outreaches to and communicates with providers to facilitate optimal care and treatment, when necessary, to educate and address clinical necessity concerns and ACD policy compliance requirements.

  • Understands department objectives, including their linkages to related areas, as well as need for OT when necessary to maintain contractual performance standards for referral and authorization processing.

  • Collaborate to operate and improve processes across departments related to the ACD Program to optimize productivity with the highest degree of attention to beneficiary and provider experience.

  
  Use your skills to make an impact
  

  Required Qualifications

  • Our Department of Defense Contract requires U.S. Citizenship

  • Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)

  • HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico.

  • Certified by the Behavior Analyst Certification Board as an applied behavioral therapist or analyst such as but not limited to an LBA, BCBA, or BCBA-D.

  • 3 or more years of experience as a Board Certified Behavior Analyst

  • 3 or more years of applied behavioral analysis (ABA) with ASD (Autism Spectrum Disorder) experience

  • Must be able to work an 8-hour shift sometime between the hours of 8:00 a.m. - 6 p.m. EST, Monday through Friday and the flexibility to work overtime based on business need. (This may involve weekends)

  Preferred Qualifications

  • Prior experience with the TRICARE Autism Care Demonstration

  • Prior experience with Utilization Review, Utilization Management, Peer Reviews and/or Quality Management

  • Knowledge of CPT codes that apply to ABA and/or experience with DMS-5 criteria

  • Experience with interpreting medical policy

  • Direct or Indirect Military experience

  Work at Home Requirements

  To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home 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

  #LI-JB2

  Scheduled Weekly Hours

  40

  Pay Range

  The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

  
  

  $63,400 - $87,400 per year

  
  

  This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

  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.

  
  Equal Opportunity Employer

  It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

• About the company

  Humana looks at every facet of your life and works with you to create a path to health that fits your unique needs

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