Humana Supervisor Referral and Authorization in Atlanta, Georgia

Role: Supervisor Referral/Authorization

Assignment: Humana Government Business

Location: Work at Home - flexible

Assignment Capsule

Supervises referral/authorization and utilization management activities within an assigned “pod” or geographic area. Ensures their assigned areas are compliant with referral/authorization management policies, procedures, and processes to maintain strict contract requirements and to promote the delivery of high quality, cost-effective care. Collects and analyzes individual and team data to determine operational efficiency and effectiveness. In addition, ensures timely and accurate processing of referrals and authorizations including benefit/medical necessity review, preauthorization, inpatient current review, discharge planning, assessment for potential quality issues, TRICARE Prime Remote and active duty claims reconciliation.

Our Department of Defense Contract requires U.S. citizenship for this position.

  • Supervises timely and accurate processing of referrals/authorizations, and utilization management activities including opportunities for assessment, monitoring, and coordinating cases with Case/Care Management programs and Quality Management as appropriate. Ensures team associates full compliance with contract requirements, policies, procedures, and performance standards. Provides oversight and direction to team associates on productivity, cost-of-care and network steerage opportunities.

  • Serves as a clinical resource for team. Provides monitoring and coordination of team’s UM, clinical and referral activities as needed. Activities may include benefit and medical necessity review, preauthorization, inpatient concurrent review/discharge planning, assessment for potential quality issues and active duty claims reconciliation Monitors for accurate pends to Medical Director, Second Level Review, Non covered benefits, and notification to Quality Management when needed. Also includes completion of travel attestation documentation when required.

  • Prioritizes caseload/assignments between associates to optimize all available resources and maintain a case load when necessary. Implements and supports contingency operations when needed or directed to meet performance standards. Works collaboratively with other supervisors and managers on opportunities to improve referral, authorization and utilization management activities for all teams.

  • Provides research and resolution of issues and concerns relating to referrals and authorizations activities including inquiries received from beneficiaries, providers, Military Treatment Facilities (MTFs) or Specialized Authorization Staff (SAS). Establishes and maintains open communication and collaborative relationships with both internal and external customers

  • Identifies and facilitates training requirements for both clinical and non-clinical associates. Develops associates for future growth opportunities by continually coaching them and completing performance management plans. Leads by example and complies with Humana Government Business Values and Leadership expectations, including recruiting, selection, orientation and on the job training of new associates.

    Role Essentials:

    · Registered Nurse with current in-state RN license

    · 3-5 years varied clinical experience

    · Effective relationship management

    · Interqual knowledge

    · Proficiency with Microsoft Office software

    · Use of health and business data and informatics

    · Good communication skills, verbal and written

    Role Desirables:

    · Three or more years of utilization or case management experience

    · UM or Case Management Certification

    · Bachelor’s Degree in nursing

    · Two years of management experience

    · Previous TRICARE experience

    · Good organizational skills

Title: Supervisor Referral and Authorization

Location: Texas-San Antonio

Other Locations: US-WI-Green Bay, US-Minnesota-Saint Paul, US-Illinois-Chicago, US-OH-Cincinnati, US-IN-Indianapolis, US-North Carolina-Charlotte, US-Missouri-Kansas City, US-GA-Atlanta, US-KY-Louisville, US-Virginia-Norfolk

Requisition ID: 174334