[Remote] Pre-Authorization Nurse at Humana

Indiana, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Registered Nurse with current in-state RN license
At least 3 years of varied clinical RN nursing experience
TRICARE experience
Knowledge of MCG evidence-based criteria or comparable (such as Interqual, etc.)
U.S. citizenship
Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Service)
Ability to provide a high-speed DSL or cable modem for a home office (25mbps download x 10mbps upload)

Responsibilities

Review prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate stakeholder
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 appropriately in MSR
Review inpatient outlier cases, ensure appropriate and timely discharge planning, and refer to Tier III care management as needed
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 InterQual 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; 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

Skills

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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