Remote Pre-Authorization Nurse: Care Utilization Expert

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

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.