Pre-Authorization Nurse

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.

Responsibilities

The Pre-Authorization Nurse 2 will assist TRICARE beneficiaries in receiving the highest quality specialty healthcare through management of the referral/authorization process. Support front line telephone agents in dealing with beneficiaries and providers. Identify and direct beneficiaries to the most appropriate, cost-effective medical care. Have an understanding of TRICARE policy and HM policies and procedures related to the processing of referrals and authorizations. Be able to apply this information in assisting beneficiaries, providers, and phone agents.

The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment and refers to internal stakeholders for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in various medical management systems. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Required Qualifications

• Associates degree in Nursing
• A minimum of 3 plus years of clinical nursing experience
• Active R.N. license in the state(s) in which the nurse is required to practice
• Ability to be licensed in multiple states without restrictions
• Proficient with MS Office products including Word, Excel and Outlook
• Ability to work independently under general instructions and with a team
• Ability to work an 8-hour shift between the hours of 8:00 a.m.-5 p.m. and have flexibility to work different shifts as needed including overtime
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Our Department of Defense contract requires U.S. Citizenship
• Successfully receive interim approval for government security clearance (eQIP – Electronic Questionnaire for Investigation Processing)

Work at Home/Remote Requirements
To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Health Plan experience working with large carriers
• 1 or more years Utilization Review and/or Prior Authorization experience
• Previous experience in case management, discharge planning and/or home health or rehab
• Experience working with MCG guidelines
• Working knowledge of ICD-9 or ICD-10, HCPCS, DRG use
• Experience with TRICARE contracts and/or the military health care delivery system
• Knowledge of TRICARE policies and programs

Additional Information

Work Style: Remote

Work hours: Monday-Friday 8 a.m. to 5 p.m. (Must also have the flexibility to work different shifts as needed and some potential overtime)

SSN Alert Statement: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide their social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.