Humana
This range is provided by Humana. Your actual pay will be based on your skills and experience – talk with your recruiter to learn more.
Base Pay Range $71,100.00/yr – $97,800.00/yr
Become a part of our caring community and help us put health first.
The Pre‑Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Coordinate care for MHS beneficiaries receiving care outside the MTF, monitor quality of care, identify and document any potential quality issues regarding the patient’s care, coordinate patient transfers, and document appropriately in MSR. Review inpatient outlier cases, ensure appropriate and timely discharge planning, and refer to Tier III care management as needed.
Responsibilities
Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines, including timely data entry in MSR.
Perform accurate and timely assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR; pend cases appropriately to second level review and follow up with any denial activities as indicated.
Complete and document in MSR accurate and timely determinations of appropriateness of level of care, taking appropriate actions to facilitate direction of patients to the correct level of care as indicated by criteria.
Direct discharge planning appropriately; maximize steerage of patients to the MTFs and preferred providers; facilitate move to alternative levels of care in a timely manner.
Identify and follow patients requiring Tier II Care Management; coordinate cases with and refer to tier III Care Manager and Disease Management Programs as appropriate.
Required Qualifications
U.S. citizenship required (Department of Defense Contract).
Successful interim approval for government security clearance (NBIS – National Background Investigation Service).
Licensed Nurse with 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).
Preferred Qualifications
Utilization Review/Quality Management experience.
BA/BSN degree.
Work‑At‑Home Requirements
Must provide a high‑speed DSL or cable modem for a home office; local contractors in California will be reimbursed for internet expense.
Minimum standard speed for optimal performance of 25 Mbps download × 10 Mbps upload is required.
Satellite and wireless internet service is NOT allowed.
Dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
Travel While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required.
Scheduled Weekly Hours 40 hours per week.
Pay Range $71,100 – $97,800 per year. The compensation range reflects a good‑faith estimate of starting base pay and may vary based on geographic location and individual qualifications. This job is eligible for a bonus incentive plan based on company and/or individual performance.
Description of Benefits Humana, Inc. offers competitive benefits designed to support whole‑person well‑being, including medical, dental, vision, 401(k), time off, disability, life insurance, and more.
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 protected veteran status. Humana also takes affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and advance individuals with disability or protected veteran status, basing all employment decisions only on valid job requirements.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Health Care Provider
Industries Insurance
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Base Pay Range $71,100.00/yr – $97,800.00/yr
Become a part of our caring community and help us put health first.
The Pre‑Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Coordinate care for MHS beneficiaries receiving care outside the MTF, monitor quality of care, identify and document any potential quality issues regarding the patient’s care, coordinate patient transfers, and document appropriately in MSR. Review inpatient outlier cases, ensure appropriate and timely discharge planning, and refer to Tier III care management as needed.
Responsibilities
Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines, including timely data entry in MSR.
Perform accurate and timely assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR; pend cases appropriately to second level review and follow up with any denial activities as indicated.
Complete and document in MSR accurate and timely determinations of appropriateness of level of care, taking appropriate actions to facilitate direction of patients to the correct level of care as indicated by criteria.
Direct discharge planning appropriately; maximize steerage of patients to the MTFs and preferred providers; facilitate move to alternative levels of care in a timely manner.
Identify and follow patients requiring Tier II Care Management; coordinate cases with and refer to tier III Care Manager and Disease Management Programs as appropriate.
Required Qualifications
U.S. citizenship required (Department of Defense Contract).
Successful interim approval for government security clearance (NBIS – National Background Investigation Service).
Licensed Nurse with 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).
Preferred Qualifications
Utilization Review/Quality Management experience.
BA/BSN degree.
Work‑At‑Home Requirements
Must provide a high‑speed DSL or cable modem for a home office; local contractors in California will be reimbursed for internet expense.
Minimum standard speed for optimal performance of 25 Mbps download × 10 Mbps upload is required.
Satellite and wireless internet service is NOT allowed.
Dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
Travel While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required.
Scheduled Weekly Hours 40 hours per week.
Pay Range $71,100 – $97,800 per year. The compensation range reflects a good‑faith estimate of starting base pay and may vary based on geographic location and individual qualifications. This job is eligible for a bonus incentive plan based on company and/or individual performance.
Description of Benefits Humana, Inc. offers competitive benefits designed to support whole‑person well‑being, including medical, dental, vision, 401(k), time off, disability, life insurance, and more.
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 protected veteran status. Humana also takes affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and advance individuals with disability or protected veteran status, basing all employment decisions only on valid job requirements.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Health Care Provider
Industries Insurance
#J-18808-Ljbffr