Humana Inc. is looking for a Pre-Authorization Nurse to join our team. You will review prior authorization requests to ensure appropriate care and setting according to guidelines and policies. Your independent judgment will be key in approving services or forwarding requests.
What You'll Do
- Coordinate care for MHS beneficiaries receiving care outside the Military Treatment Facility (MTF).
- Monitor quality of care, identify, and document any potential quality issues regarding patient care.
- Coordinate patient transfers and document appropriately in MSR.
- Review inpatient outlier cases, ensure timely discharge planning, and refer to Tier III care management as needed.
- Perform prior authorization reviews according to established Humana Government Business contractual requirements and guidelines.
- Perform accurate and timely assessment and concurrent review of outlier admissions using InterQual criteria.
- Pend cases appropriately to second level review and follow up with any denial activities.
- Complete accurate determinations of appropriateness of level of care and take action to direct patients to the correct level.
- Direct discharge planning appropriately, maximize steerage of patients to MTFs and preferred providers, and facilitate moves to alternative levels of care.
- Identify and follow patients requiring Tier II Care Management, coordinating with and referring to Tier III Care Managers and Disease Management Programs.
What We're Looking For
- U.S. citizenship (Department of Defense Contract requirement).
- Ability to successfully receive interim approval for a government security clearance (NBIS).
- Cannot live in Puerto Rico per government contract.
- Registered Nurse with a current, in-state RN license.
- At least 3 years of varied clinical RN nursing experience.
- Current TRICARE experience.
- Current knowledge of MCG evidence-based criteria or comparable (such as Interqual).
Nice to Have
- Utilization Review or Quality Management experience.
- A BA or BSN degree.
Technical Stack
- MSR
Benefits & Compensation
- Compensation: $71,100 - $97,800 per year.
- Medical, dental, and vision benefits.
- 401(k) retirement savings plan.
- Comprehensive time off, including paid time off, company/personal holidays, volunteer time off, and paid parental and caregiver leave.
- Short-term and long-term disability insurance.
- Life insurance.
Work Mode
This is a fully remote position.
Become a part of our caring community and help us put health first. 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 protected veteran status.
