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

Are you looking to join a team where you can be a part of our important mission of supporting the TRICARE healthcare program for our nation's military and use your data skills? Humana Government Business is a top 10 Department of Defense contractor, with a long history in the TRICARE business and has been awarded the T-5 East Region, the next generation of military health contracts.
The Director, Referrals process referrals from Military Treatment Facilities (MTFs) and civilian providers. The Director, Referrals requires an in-depth understanding of how organization capabilities interrelate across the function or segment.

The Director, Referrals has oversight for team handling data entry into medical management system, assigning an appropriate provider, reviewing for benefits, and/or medical necessity as required or pending to a nurse or supervisor who can complete or request additional information. Recognizes a sensitive diagnoses and/or referral requiring Case Management, and pend to appropriate point of contact for review. Understands TRICARE benefits/limitations and Humana Military referral processes, MOUs with MTFs, and referral and UM policies. Answers questions or contacts MTFs and/or civilian providers to obtain additional information that may be required to complete referral etc. Requires assigning appropriate ICD10 code to referral as well as appropriate CPT Code. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy.

Key Accountabilities

• Ensures associates comply with DHA and HGB policy. Provide reporting required by contract. Serves as the point of contact (POC) for the DHA Referrals SME and for all referral issues in the East TRICARE region.

• Integrate clinical elements of Cost of Care programs

• Develop and direct clinical field internal quality reviews pertaining to Case Management and Utilization Management, which contribute to Care Management, and maximize efficiency and effectiveness of health safety for beneficiaries.

• Provide efficient integrative management to meet initiatives of HGB.

• Identify variances in reviewer activity and UM trends, and direct corrective intervention.

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.

• Professional Registered Nurse with valid license

• Bachelor’s degree in health-related field

• 5 years of management experience

• 5 years of RN Clinical experience

• 5 years of broad healthcare delivery experience

Preferred Qualifications

• Professional certification in case management, or quality management (such as Certification in Managed Care Nursing (CMCN), Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM)

• Military healthcare experience

• TRICARE experience

• Graduate degree in business or related field

#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 will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$136,200 - $187,400 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.