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TRICARE Prior Authorization Nurse - Honolulu, HI - Full-time / Part-time
| Hours | Full-time, Part-time |
|---|---|
| Location | Honolulu, HI Honolulu, Hawaii |
About this job
TRICARE! Prior Authorization! HONOLULU, HI
Talk about meaningful work. Talk about an important role. Let's talk about your next career move. Our UnitedHealthcare Military & Veterans organization has been selected to provide quality health care services for those who serve our nation. This is an opportunity to share in something special; an opportunity for all of us to serve those families who have made our nation stronger. It's an inspiring role and it can inspire your career. Find out more about these opportunities to do your life's best work. (sm)
Due to continued growth, UnitedHealthcare Military and Veterans is currently seeking a Prior Authorization Nurse who would be responsible for determining medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Generally work is self-directed and not prescribed. The Prior Authorization Nurse works under the direct supervision of PA Manager or MD.
This is a telecommuter position for internal candidates; External candidates will need to work in the offices for 6 month before telecommuting: Office location is 3049 Ualena Street, Honolulu
Primary Responsibilities:
- Reviewing requests for services for benefit determinations and medical necessity in accordance with Milliman Care Guidelines and TRICARE Policy Manuals
- Assesses and interprets customer needs and requirements
- Reviewing cases and analyzing clinical information in conjunction with Medical Directors to determine the appropriateness of services
- Performing Clinician to Physician interaction to acquire additional clinical information or discuss alternatives to current treatment plan
- Escalating cases to the Medical Director for case discussion or peer-to-peer intervention as appropriate
- Referring patients to disease management or case management programs
- Documenting activities according to established standards
- Identifies solutions to non-standard requests and problems
- Solves moderately complex problems and/or conducts moderately complex analyses
- Works with minimal guidance; seeks guidance on only the most complex tasks
- Provides explanations and information to others on difficult issues
.
Requirements
Required Qualifications:
- Current and unrestricted RN License
- RN License must be for the State of Hawaii OR you must be in process of actively obtaining an RN License for Hawaii
- Minimum 3 years of clinical experience as a nurse
- Intermediate computer skills (i.e. Microsoft Word, Outlook and Internet) with the ability to navigate a Windows environment
- United States Citizenship
- Ability to obtain favorable adjudication following submission of Department of Defense
- Strong organizational skills
- Demonstrated ability to assist with focusing activities toward a strategic direction as well as develop tactical plans, drive performance and achieve targets
- Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
- Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
Preferred Qualifications:
- Previous TRICARE Experience
- Knowledge of Milliman Care Guidelines
- A background that involves prior authorization review for an insurance company or in a managed care environment is a plus
- Utilization Management experience
As a requirement of UnitedHealth Group's contract with the Department of Defense, this position requires U.S. citizenship and proof of favorable adjudication following submission of Department of Defense , (the National Agency Check Legal and Credit or “NACLCâ€). Successful completion of the NACLC process is a requirement for continued employment in this role. NACLC processing will be initiated by our TRICARE Security Officer post-offer, and can take 3-6 months for a final decision communication from the Department of Defense. Candidates will be allowed to begin employment with UnitedHealth Group in this role based on an interim clearance, and final results will be communicated as they are received. Failure to obtain final NACLC approval will result in termination from this role.
Careers at UnitedHealthcare Military & Veterans. When it comes to their health care, the men and women who help keep the peace deserve the greatest peace of mind. That's why UnitedHealthcare is the organization that's called on to serve them and their loved ones. We're all about finding better ways to help improve their lives no matter where life may take them. So our career opportunities take challenge to a higher level. If you have a commitment to quality that mirrors our commitment to the men and women of the armed forces, take time to learn more about the career paths available here. It's a genuine opportunity to do your life's best work. (sm)
Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: RN, Nurse, Tricare, Military, Veterans, Prior Authorization, Managed Care, HI, Hawaii, Honolulu, Milliman, Utilization Review, Utilization Management, UM, Case Management, UHC, UnitedHealth Care, UHG, UnitedHealth Group, Nursing jobs, Nursing careers, RN careers or RN job
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