Pre-Authorization Nurse

** 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 forward 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.

** Use your skills to make an impact*
* ** Required Qualifications*
* + Our Department of Defense Contract requires U.S. citizenship for this position

+ Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Service)

+ HGB is not authorized to do work in Puerto Rico per our government contract.  We are not able to hire candidates that are currently living in Puerto Rico.

+ 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, etc.)

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** Preferred Qualifications*
* + Utilization Review/Quality Management experience

+ BA/BSN degree

** Work-At-Home Requirements*
* + WAH requirements:
Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

+ A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

+ Satellite and Wireless Internet service is NOT allowed for this role.

+ A 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

** Pay Range*
* The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay 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.

$71,100 - $97,800 per year

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

** Description of Benefits*
* Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k)…