Pre-Authorization Nurse

This range is provided by Humana. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$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 Pre‑Authorization Nurse 2 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.

• Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines to include timely data entry in MSR.
• Perform accurate and timely assessment and concurrent review of outlier admissions using Inter Qual 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: take appropriate actions to facilitate direction of patients to 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.

• U.S. citizenship required (Department of Defense contract).
• Interim approval for government security clearance (NBIS - National Background Investigation Service).
• Cannot work in Puerto Rico per contract; current residents of Puerto Rico cannot be hired.
• Registered 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 Inter Qual).

• Utilization Review / Quality Management experience.
• BA/BSN degree.

• Must provide a high‑speed DSL or cable modem for a home office; contractors in California provided payment for their internet expense.
• Minimum internet speed: 25 mpbs download × 10 mpbs upload.
• Satellite and wireless internet service is NOT allowed.
• Dedicated space lacking 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

$71,100 - $97,800 per year. The compensation 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. This job is eligible for a bonus incentive plan.

Humana, Inc. and its affiliated subsidiaries offer competitive benefits: medical, dental, vision, 401(k), paid time off and holidays, volunteer time off, paid parental and caregiver leave, short‑term & long‑term disability, life insurance, and more.

Humana Inc. (NYSE: HUM) is committed to putting health first for teammates, customers and the company. Through our insurance services and Center Well healthcare services, we help millions achieve best health.

Humana does not discriminate on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. Humana takes affirmative action per Section 503 of the Rehabilitation Act and VEVRAA.

Mid‑Senior level

Full‑time

Health Care Provider

Insurance