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

40

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.