Pre-Authorization Nurse

NurseRemotely; United States; Remote; USD 71,000 - 98,000; Full time

Job summary

Humana is seeking a Pre-Authorization Nurse 2 to review requests for medical necessity and level of care, using clinical judgment and guidelines. The role supports education of providers and data entry in clinical systems, with opportunities to work remotely and occasional travel for trainings.

A strong RN background, Indiana licensure, and multitier licensure readiness are required. Applicants should have familiarity with utilization management or case management, plus MS Office proficiency and

Qualifications

• 2+ years of RN experience.
• Active RN license in the state of Indiana.
• Ability to be licensed in multiple states without restrictions.
• Experience in utilization management or case management preferred.
• Proficient with Word, Excel and Outlook.
• Able to work independently and with a team.

Responsibilities

• Review prior authorization requests for medical necessity and level of care.
• Educate providers on utilization and medical management processes.
• Enter and maintain clinical information in medical management systems.
• Interpret guidelines and follow organizational procedures.
• Make independent decisions with minimal direction when needed.
• Travel to Humana offices for training or meetings as required.

Skills

RN experience

Indiana RN license

Multistate licensure

Utilization management

MS Office proficiency

Independent working

Education

Bachelor's degree

Tools

MS Office

Job description

Become a part of our caring community

The Pre-Authorization Nurse reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward 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 completes medical necessity and level of care reviews for requested services using clinical judgment, and refers to team members for review depending on case findings. Educate providers on utilization and medical management processes. Enter and maintain relevant clinical information in various medical management systems. Understand 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

• 2+ years of RN experience
• Active RN license in the state of Indiana
• Ability to be licensed in multiple states without restrictions
• Previous experience in utilization management, case management, discharge planning and/or home health or rehab
• Proficient with MS Office products including Word, Excel and Outlook
• Ability to work independently under general instructions and with a team

Preferred Qualifications

• Bachelor's degree
• MCO experience
• Health Plan experience working with large carriers
• Previous Medicare/Medicaid experience
• Outpatient or home health experience in Utilization Management
• Experience working with MCG or Interqual guidelines

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The 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 will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$71,100 - $97,800 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

About Humana: 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. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.