Pre-Authorization Nurse

Pre-Authorization Nurse 2

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 responsibilities include interpreting and independently determining appropriate courses of action, coordinating care for beneficiaries, monitoring quality, managing patient transfers, and ensuring timely discharge planning.

• 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, and 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.
• Successful interim approval for government security clearance (NBIS – National Background Investigation Service).
• Restricted to candidates not currently living in Puerto Rico per government contract.
• Registered Nurse with a 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 (e.g., Inter Qual).

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

• Must have a high‑speed DSL or cable modem available for a home office;
  California‑based associates or contractors may receive reimbursement for internet expenses.
• Minimum standard speed for optimal performance: 25 Mbps download × 10 Mbps upload.
• Satellite and wireless internet service is not allowed for this role.
• A dedicated space with minimal interruptions to protect PHI/HIPAA information.

Remote position with occasional travel to Humana offices for training or meetings.

40 hours per week.

$71,100 – $97,800 per year (base salary).

Humana, Inc. benefits include medical, dental, and vision coverage; a 401(k) retirement plan; paid time off; short‑ and long‑term disability; life insurance; and additional wellness programs that support whole‑person well‑being.

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 also takes affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and advance individuals with disabilities or protected veteran status, basing all employment decisions only on valid job requirements.

Mid‑Senior level.

Full‑time.

Health Care Provider.

Insurance.