Pre-Authorization Nurse

Humana • Topeka, KS • 6h ago

Become a part of our caring community and help us put health first

Key Accountabilities -

· You will 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 in MSR. Review inpatient outlier cases, ensure appropriate and timely discharge planning, and refer to Tier III care management as needed.

· You will perform prior authorization reviews according to established HGB contractual requirements and guidelines to include data entry in MSR.

· You will perform accurate assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR. Pend cases to second level review and follow up with any denial activities as indicated.

· You will 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.)

? 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

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) 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.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Humana

Go to Apply

Share this job

Similar Jobs

Industrial-Organizational (I-O) Psychologist

GAP Solutions Inc • Topeka, KS • 4h ago

Hospital & Medical

NOTE: THIS POSITION IS FULLY REMOTE! Position Objective: Provide services as an Industrial-Organizational (I-O) Psychologist in support of the overall functions of the Dept. of Homeland Security (DHS), U.S. Immigration a...

4h ago

Go to Apply

Physical Therapist Assistant PTA Home Health PRN

Elara Caring • Lawrence, KS • 8h ago

Hospital & Medical

At Elara Caring, we have a unique opportunity to play a huge role in the growth of an entire home care industry. Here, each employee has the chance to make a real difference by carrying out our mission every day. Join ou...

8h ago

Go to Apply

Medicaid State Technology Lead

Humana • Topeka, KS • 21h ago

Hospital & Medical

Become a part of our caring community and help us put health first The State Technology Lead understands departmental and IT organizational strategy and operating objectives, including their linkages to related areas. Th...

21h ago

Go to Apply

Speech Language Pathologist - Travel Contract

Jackson Therapy Partners • Topeka, KS • 1d ago

Hospital & Medical Sponsored

Join Jackson Therapy Partners as a travel SLP and use your skills where they’re needed most. You’ll help patients improve communication and swallowing disorders while exploring a new part of the country. Apply today and...

1d ago

Go to Apply

Medical Director, Oncology / GI Subspecialty

Parexel • Topeka, KS • 2d ago

Hospital & Medical

During the last five years, Parexel has participated in more than 1,000 Oncology and Hematology clinical projects. The range of services includes compound clinical development planning, collaboration with feasibility, pr...

2d ago

Go to Apply

LPN or RN

Advena Living on Tenth • Topeka, KS • 2d ago

Hospital & Medical

This job was posted by https://www.kansasworks.com : For more information, please see: https://www.kansasworks.com/jobs/13519296 We are excited to add a Nurse RN/LPN to our dedicated team. As the Nurse RN/LPN you will en...

2d ago

Go to Apply

Advanced Practice Nurse (Nurse Practitioner) - Specialty Care

Veterans Affairs, Veterans Health Administration • Topeka, KS • 3d ago

Hospital & Medical

Summary The Advanced Practice Nurse (APN) Certified Nurse Practitioner (NP) practices in Hematology/Oncology Service to provide a full range of services emphasizing quality, timeliness, and the advancement of the Veteran...

3d ago

Go to Apply

Medical Director - Ophthalmology

Parexel • Topeka, KS • 3d ago

Hospital & Medical

Parexel is in the business of improving the world's health. We do this by providing a suite of biopharmaceutical services that help clients across the globe transform scientific discoveries into new treatments. From clin...

3d ago

Go to Apply

Federal Clinical Measurement Support Nurse (DHA CQM Program)

St. George Tanaq Corporation • Topeka, KS • 4d ago

Hospital & Medical

Federal Clinical Measurement Support Nurse (DHA CQM Program) Fully Remote-United States Job Type Full-time Description Overview Tanaq Management Services (TMS) delivers professional, scientific, and technical services an...

4d ago

Go to Apply

Federal Clinical Quality Management Program Manager (Part-time, DHA)

St. George Tanaq Corporation • Topeka, KS • 4d ago

Hospital & Medical

Federal Clinical Quality Management Program Manager (Part-time, DHA) Fully Remote-United States Job Type Part-time Description Overview Tanaq Management Services (TMS) delivers professional, scientific, and technical ser...

4d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.