Humana
Pre‑Authorization Nurse 2 – Humana
Get AI‑powered advice on this job and more exclusive features.
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
Overview Review prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate stakeholder. The work assignments require interpretation and independent determination of the appropriate courses of action.
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; document review results in MSR and pend cases appropriately to second level review.
Complete and document in MSR accurate and timely determinations of appropriateness of level of care and facilitate direction of patients to correct level of care.
Direct discharge planning appropriately; facilitate move to alternative levels of care in a timely manner.
Coordinate care for MHS beneficiaries receiving care outside the MTF; monitor quality of care, identify and document any potential quality issues.
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.
Identify and follow patients requiring Tier II Care Management; coordinate cases with and refer to Tier III Care Manager and Disease Management Programs.
Required Qualifications
U.S. citizenship (Department of Defense Contract requirement).
Interim approval for government security clearance (NBIS).
Cannot be hired if currently living in Puerto Rico due to contract restrictions.
Registered Nurse with current in‑state RN license.
At least 3 years of varied clinical RN nursing experience.
Current TRICARE experience.
Knowledge of MCG evidence‑based criteria or comparable (InterQual, etc.).
Preferred Qualifications
Utilization Review/Quality Management experience.
BA/BSN degree.
Work‑At‑Home Requirements
Must have high‑speed DSL or cable modem for a home office.
Minimum 25 Mbps download × 10 Mbps upload; satellite and wireless internet services not allowed.
Dedicated space free from 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.
Weekly Hours 40 hours
Pay Range $71,100 – $97,800 per year; may vary by location and qualifications. Eligible for a bonus incentive plan.
Description of Benefits Competitive benefits including medical, dental, vision, 401(k), paid time off, short‑term and long‑term disability, life insurance, and more.
About Us Humana, Inc. is committed to putting health first for our teammates, customers, and company. We offer services to millions of people across Medicare, Medicaid, families, individuals, military service personnel, and communities.
Equal Opportunity Employer Humana does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. Humana takes affirmative action and follows federal requirements for employees with disability or protected veteran status.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
Industries Insurance
#J-18808-Ljbffr
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
Overview Review prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate stakeholder. The work assignments require interpretation and independent determination of the appropriate courses of action.
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; document review results in MSR and pend cases appropriately to second level review.
Complete and document in MSR accurate and timely determinations of appropriateness of level of care and facilitate direction of patients to correct level of care.
Direct discharge planning appropriately; facilitate move to alternative levels of care in a timely manner.
Coordinate care for MHS beneficiaries receiving care outside the MTF; monitor quality of care, identify and document any potential quality issues.
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.
Identify and follow patients requiring Tier II Care Management; coordinate cases with and refer to Tier III Care Manager and Disease Management Programs.
Required Qualifications
U.S. citizenship (Department of Defense Contract requirement).
Interim approval for government security clearance (NBIS).
Cannot be hired if currently living in Puerto Rico due to contract restrictions.
Registered Nurse with current in‑state RN license.
At least 3 years of varied clinical RN nursing experience.
Current TRICARE experience.
Knowledge of MCG evidence‑based criteria or comparable (InterQual, etc.).
Preferred Qualifications
Utilization Review/Quality Management experience.
BA/BSN degree.
Work‑At‑Home Requirements
Must have high‑speed DSL or cable modem for a home office.
Minimum 25 Mbps download × 10 Mbps upload; satellite and wireless internet services not allowed.
Dedicated space free from 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.
Weekly Hours 40 hours
Pay Range $71,100 – $97,800 per year; may vary by location and qualifications. Eligible for a bonus incentive plan.
Description of Benefits Competitive benefits including medical, dental, vision, 401(k), paid time off, short‑term and long‑term disability, life insurance, and more.
About Us Humana, Inc. is committed to putting health first for our teammates, customers, and company. We offer services to millions of people across Medicare, Medicaid, families, individuals, military service personnel, and communities.
Equal Opportunity Employer Humana does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status. Humana takes affirmative action and follows federal requirements for employees with disability or protected veteran status.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
Industries Insurance
#J-18808-Ljbffr