[Hiring] Pre-Authorization Registered Nurse @Humana

Role Description

The Pre-Authorization Nurse 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 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

• Completes medical necessity and level of care reviews for requested services using clinical judgment.
• 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.
• Follows established guidelines/procedures.

Qualifications

• Active Licensed Registered Nurse (RN) in the state of Virginia or obtain a license in a state that participates in the compact license (eNLC) with no disciplinary action.
• Minimum two (2) years varied clinical nursing experience in an acute care, skilled or rehabilitation setting.
• Previous experience in utilization management, case management, discharge planning and/or home health or rehab.
• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms.
• Ability to troubleshoot and resolve 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 (preferred).
• Certification in Case Management (CCM) or Managed Care Nursing (CMCN) (preferred).
• Experience working with MCG or Interqual guidelines (preferred).

Benefits

• Medical, dental and vision benefits.
• 401(k) retirement savings plan.
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance.
• Many other opportunities supporting whole-person well-being.

Company Description

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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.