Pre-Authorization Registered Nurse

Humana Inc; Virginia (MN); Hybrid; USD 71,000 - 98,000; Full time

Benefits offered by this job

Health benefits

401(k)

Paid time off

Job summary

Humana Inc. is seeking a Pre-Authorization Nurse to review prior authorization requests, determine medical necessity, and educate providers on utilization management processes.

The role requires clinical judgment, independent decision making, and the ability to navigate multiple systems in a remote environment. Candidates should have an active RN license (Virginia or compact state), 2+ years of acute or rehab nursing, and knowledge of case management, discharge planning, or home health.

Qualifications

• Active RN license in Virginia or a compact state (eNLC) with no disciplinary action.
• Minimum two years of varied clinical nursing experience in acute, skilled or rehab settings.
• Experience in utilization management, case management, discharge planning and/or home health or rehab.
• Proficient in MS Office (Word, Excel, PowerPoint) and navigating multiple systems in a remote environment.
• Ability to work independently under general instructions and with a team.

Responsibilities

• Reviews prior authorization requests for appropriate care and setting, following guidelines and policies.
• Makes determinations on medical necessity and level of care for requested services.
• Educates providers on utilization management processes.
• Enters and maintains pertinent clinical information in medical management systems.
• Interprets guidelines and participates in reviews with internal stakeholders as needed.

Skills

RN license

Clinical nursing

Utilization management

Discharge planning

Remote work

Tools

MS Office

EMR systems

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 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 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

• 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 and ability to troubleshoot and resolve basic technical difficulties in a remote environment
• Ability to work independently under general instructions and with a team

Preferred Qualifications

• Health Plan experience working with large carriers
• Previous Medicare/Medicaid experience
• Certification in Case Management (CCM) or Managed Care Nursing (CMCN)
• Experience working with MCG or Interqual guidelines

Additional Information

• Workstyle: Remote work at home
• Location: Virginia or reside in a state participating in a compact license, (eNLC)
• Travel: Less than 5% for market meetings as business needs.
• Hours: Must be able to work 8 hours Monday through Friday between 8:00 AM to 5:00 PM Eastern- May be required to work rotating holidays or weekends as determined by business needs
• 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 year This 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.