Senior Clinical Senior Market Development Professional - Registered Nurse

Profile

Description

The Senior Market Development Professional provides support to assigned health plan and/or specialty companies relative to Medicare/Medicaid/TRICARE 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.

Responsibilities

Location: work at home anywhere

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 Medicare/Medicaid/TRICARE 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


Role Essentials


Associates degree in Nursing
Registered Nurse
5 or more years of clinical experience
Excellent communication skills, both oral and written
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
Pre-authorization or utilization management experience
Behavioral health
Medicaid 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

Company info

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