[Hiring] Pre-Authorization Nurse @Humana

Role Description

The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Pre-Authorization Nurse 2 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.

Responsibilities

• Send and receive telephonic calls averaging 50% communication with providers
• Educate providers on utilization and medical management processes
• Enter and maintain pertinent clinical information in various medical management systems
• Understand own work area professional concepts/standards, regulations, strategies and operating standards
• Make decisions regarding own work approach/priorities and follow direction
• Work is managed and often guided by precedent and/or documented procedures/regulations/professional standards with some interpretation

Qualifications

• Must reside in Oklahoma
• Registered Nurse, compact nursing license
• 3+ years of clinical nursing experience
• Intermediate to Advanced knowledge of MS Office including Word, Excel, PowerPoint, and Teams in a Windows based environment
• Ability to quickly learn new systems and troubleshoot basic technical difficulties in a remote environment
• Ability to work independently under general instructions and with a team

Requirements

• Health Plan experience working with large carriers (preferred)
• Previous Medicare/Medicaid experience a plus (preferred)
• Previous experience in pre-authorization, utilization management, case management, discharge planning and/or home health or rehab (preferred)
• Experience working with MCG or Interqual guidelines (preferred)

Benefits

• Paid time off, holidays, volunteer time and jury duty pay
• Recognition pay
• 401(k) retirement savings plan with employer match
• Tuition assistance
• Scholarships for eligible dependents
• Parental and caregiver leave
• Employee charity matching program
• Network Resource Groups (NRGs)
• Career development opportunities