Pre-Authorization Nurse

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 role requires varied assignments that frequently require interpretation and independent determination of the appropriate courses of action.

• Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines, including timely data entry in MSR.
• Accurately and timely assess and concurrently review outlier admissions using Inter Qual criteria and document review results in MSR; pend cases appropriately for second level review and follow up with any denial activities.
• Complete and document in MSR accurate determinations of appropriateness of level of care, taking 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 by Department of Defense Contract.
• Interim approval for government security clearance (NBIS).
• HGB cannot work in Puerto Rico; applicants must not currently live there.
• 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 Interqual).

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

• Must provide a high‑speed DSL or cable modem for home office;
  California associates/contractors receive payment for internet expense.
• Minimum 25 Mbps download × 10 Mbps upload speed required.
• Satellite and wireless internet service not allowed.
• A dedicated, interruption‑free space 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

Pay Range: $71,100 - $97,800 per year. (Compensation may vary based on geographic location, individual pay will vary based on demonstrated job‑related skills, knowledge, experience, education, certifications, etc.)

This job is eligible for a bonus incentive plan, based upon company and/or individual performance.

Humana, Inc. and its affiliated subsidiaries provide competitive benefits including medical, dental, and vision coverage, 401(k) retirement savings plan, paid time off, including planned holidays, volunteer time off, paid parental and caregiver leave, short‑term and long‑term disability, life insurance, and other opportunities.

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

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. It 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, based on valid job requirements.

• Mid‑Senior level

• Full‑time

• Health Care Provider

• Insurance