RN Patient Care Coordinator - TRICARE
Become a part of our caring community and help us put health firstThe RN Patient Care Coordinator reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The RN Patient Care Coordinator work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The RN Patient Care Coordinator 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. Understands TRICARE policy and HM policies and procedures related to the processing of referrals and authorizations; able to apply this information in assisting beneficiaries, providers, and phone agents.
The RN Patient Care Coordinator 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.
Use your skills to make an impact
- Associate degree in nursing
- **Experience working with MCG and/or InterQual guidelines**
- A minimum of 3 plus years of clinical nursing experience
- Active R.N. license in the state(s) in which the nurse currently resides
- 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
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- Our Department of Defense contract requires U.S. Citizenship
- Must successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
Required Work Schedule:
- Virtual Training will start day one of employment and runs the first 6 to 8 weeks, 8 hours per day (hours may vary), Monday through Friday.
- You must be on camera / camera ready during training and for other meetings required by leadership.
- Attendance is vital for success, so no time off is allowed during training or within your first 120 days, with the exception of observed (and paid) company holidays.
- Hours following training are an 8-hour shift between the hours of 7:30 AM to 5:00 PM in the time zone in which you are located, Monday through Friday , subject to change based on business needs.
- Must have the flexibility to work different shifts as needed, including some potential overtime, including weekends and holidays. We strive to provide advance notice for holidays, overtime, and weekends; however, some may occur with short notice, depending on business needs.
- The initial 120 days of employment as an RN Patient Care Coordinator constitute an appraisal period. This Appraisal Period is essential to your learning and development, which is why we ask for perfect attendance during both the classroom training and mentorship periods.
- This position requires learning many systems, policies, and tools, and it takes time to become proficient in the role. You must be willing to remain in this position for a period of twelve (12) months before applying to other Humana opportunities outside the Humana TRICARE Team.
- Health plan experience working with large managed care organizations
- 1 or more years Utilization Review and/or Prior Authorization experience
- Previous experience in Case Management, Discharge Planning and/or Home Health or Rehab
- Working knowledge of ICD-10, HCPCS, DRG use
- Experience with TRICARE contracts and/or the military health care delivery system
- Knowledge of TRICARE policies and programs
Work at Home Guidance
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.
**PLEASE MAKE SURE YOU ATTACH YOUR RESUME TO YOUR APPLICATION (PDF OR WORD FORMAT) **
Modern Hire Assessment
As part of our hiring process for this opportunity, we will be using technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from [email protected] with instructions on how to add the information into your official application on Humana’s secure website.
Scheduled Weekly Hours40
Pay RangeThe 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 BenefitsHumana, 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.
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 because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.