Pre-Authorization Nurse - Remote

Overview

The Pre-Authorization Nurse 2 is responsible for reviewing prior authorization requests, ensuring compliance with guidelines, and coordinating care for beneficiaries. This role involves monitoring quality of care and facilitating patient transfers.

In Short

• Review prior authorization requests for appropriate care.
• Coordinate care for beneficiaries receiving care outside the MTF.
• Monitor quality of care and document potential issues.
• Perform assessments and concurrent reviews using established criteria.
• Facilitate timely discharge planning and referrals.
• Document determinations of care appropriateness in MSR.
• Identify patients requiring Tier II Care Management.
• Work from home with specific internet requirements.
• Occasional travel to Humana's offices for training.
• Competitive salary and benefits package.

Requirements

• U.S. citizenship required.
• Registered Nurse with current in-state RN license.
• At least 3 years of clinical RN experience.
• Current TRICARE experience.
• Knowledge of MCG or InterQual criteria.
• Utilization Review/Quality Management experience preferred.
• BA/BSN degree preferred.
• Ability to provide a high-speed internet connection.
• Dedicated workspace for protecting PHI/HIPAA information.
• Must comply with government security clearance requirements.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off and holidays.
• Short-term and long-term disability insurance.
• Life insurance and other opportunities.