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

The 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
 

Required Qualifications:

• Associate 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 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.

Preferred Qualifications:

• 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
• Experience working with MCG and/or InterQual guidelines
• 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