at Humana in Springfield, Illinois, United States
Job Description
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. This associate will conduct clinical necessity reviews for requested ABA services when approving all treatment plans (TPs), initial authorization requests, and every six-month reauthorization thereafter. Associate will utilize specified UM tools to assist in guiding clinical decisions, reviewing for appropriate care and setting, following guidelines and policies, and approve services or forward requests to necessary stakeholders as required and appropriate. Enters and maintains pertinent clinical information in various medical management systems. The associate understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines / procedures, utilizes behavioral health knowledge and skills to support the coordination, documentation, and communication of medical services and / or benefit administration determinations. The BCBA’s work assignments are varied and involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors, frequently requiring interpretation and independent determination of the appropriate courses of action.
Humana Government Business government contract requires U.S. citizenship for this position.
Role Responsibilities
Tasks include, but are not limited to:
70% : Performing utilization management activities for assigned areas. Ensures full compliance with contract requirements, policies and procedures, and performance standards. Coordinates and implements contingency operations when needed.
+ Perform accurate and timely initial and ongoing treatment reviews with documentation in MSR 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 moderately complex to complex issues and policies and procedures to determine the best and most appropriate treatment, care, or services for ACD participants.
+ Review ABA TPs for policy compliance
+ Review pend queues for pended authorizations
+ Approve clinically necessary and appropriate ABA services
+ Review outcome measures to ensure compliance with ACD policy
+ Coordinates, conducts outreach, and communicates with providers, beneficiaries, or other parties to facilitate optimal care and treatment, when necessary, to educate and address clinical necessity concerns and ACD policy compliance requirements.
+ Facilitating communication as needed between all departments within Humana Government Business and Humana corporate to resolve escalated issues and ensure the enterprise understand the function of the ACD team. Understanding and engaging in risk management procedures and analysis.
+ Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas, as well as need for overtime, weekend, and holiday coverage when necessary to maintain contractual performance standards for referral and authorization processing.
15% : Collaborate with all Humana operations departments to operate and improve processes related to specialty team(s) effectiveness with the highest degree of attention to beneficiary and provider experience.
+ Optimize staff productivity surrounding process management.
+ Strategical look for interventions and methods to improve performance.
10% : Strategize with all leaders within the ACD team and Specialty team to make recommendations to the DHA or Humana Government Business to improve policy which may relate to better case management outcomes, improved utilization management, prevention or identification of fraud waste and abuse, and trend data.
5% :Other tasks as assigned
Use your skills to make an impact
Required Qualifications
+ BCBA (Board Certified Behavior Analyst) Certification
+ 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 reside in the continental United States in the Eastern, Central, or Mountain time zone.
+ Above average written and verbal skills, including organizational abilities
+ Proficiency in Microsoft Office programs specifically Word, Excel, and Outlook
+ Ability to handle multiple projects simultaneously and to prioritize appropriately
+ Our Department of Defense Contract requires U.S. citizenship for this position
+ Successfully receive interim approval for government security clearance (NBIS – National Background Investigation Services, previously known as eQIP – Electronic Questionnaire for Investigation Processing)
Required Work Schedule
+ Training is mandatory for the first 4 – 6 weeks from 8:00 AM – 5:00 PM Eastern time, Monday – Friday.
+ Following training, must be able to work an 8-hour shift between the hours of 8:00 AM – 6:00 PM Eastern time, Monday – Friday.
+ Overtime, weekends, and holidays may be required, based on business needs.
Preferred Qualifications
+ Prior experience with the TRICARE Autism Care Demonstration
+ Knowledge of and experience with applied behavior analysis and integrated care needs for those with autism
+ 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
+ Prior experience with outcome measure assessments to include PDDBI, Vineland, SRS and/or PSI-SIPA
+ Experience with interpreting medical policy
+ Direct or indirect military experience a plus
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 and Wireless Internet service is NOT allowed for this role
+ 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.
Additional Information
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I nterview Process
As part of our hiring process for this opportunity, we will be using technology called HireVue / Modern Hire to enhance our hiring and decision-making ability. HireVue / Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.?
+ Text Prescreen : Shortly after submitting your application, you may receive both a text message and email requesting you to complete 10 to 15 prescreen questions with either yes or no answers. The text message may arrive prior to the email. If you prefer to answer via computer or tab
