Location: Lancaster, SC
Location Type: Lancaster – Remote
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.
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.
- 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
- 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
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.
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
This is a remote position
Scheduled Weekly Hours
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 decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$69,800 – $96,200 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) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
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