Become a part of our caring community and help us put health firstThe Senior Market Development Professional provides support to assigned health plan and/or specialty companies relative to commercial Medicare & Medicaid product implementation, operations, contract compliance, and federal contract application submissions. The Senior Market Development Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Location: remote

The Clinical Senior Market Development Professional serves as the primary resource on regulations for all assigned health plans. Ensures that assigned health plans are meeting or exceeding corporate commercial Medicare & Medicaid performance benchmarks. Maintains relationships with regulators within a region. In this role you will:

• Developing and creating pre-authorization lists by each state

• Complete initial Mental Health Parity and Addiction Equity Act (MHPAEA) analysis and ongoing analysis as required by policy. Analysis includes, but may not be limited to:

  • Evaluation of clinical criteria or research of available literature available to develop a clinical policy for services proposed to be added to the Preauthorization List (PAL)

  • Quality of care concerns

  • Potential for under/over-utilization

• Perform clinical and system audits, as needed

• Evaluating and documenting state requirements

• Providing recommendation on services based on research/analysis

• Review/recommend categorization of codes for external PAL

• Provide clinical insight for new code roll out

• Provide trigger codes for dashboard development/maintenance and claim analysis, as well as ad hoc reporting.

• Analyze reporting for presentation and review in MCD leader meetings

Use your skills to make an impact

Role Essentials

• Associates degree in Nursing

• Registered Nurse

• 5 or more years of experience in a clinical bedside nursing setting

• 3 or more years of in utilization management experience

• Excellent communication skills, both oral and written

• Experience analyzing data

• Experience implementing and measuring success on complex health-related initiatives

• Strategic thinker with ability to work independently

• Strong relationship building skills

• Strong analytical skills

• Process-focused, with ability to leverage and enhance existing processes

Role Desirables

• BSN degree

• Auditing experience

• Healthcare experience

Additional Information

Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.

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 will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$76,800 - $105,800 per yearThis 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 usHumana 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.