Remote RN: Utilization & Pre-Auth Specialist

Humana Inc; Oklahoma City (OK); Remote; USD 71,000 - 98,000; Full time

Benefits offered by this job

Bonus incentive plan

Job summary

Humana, Inc. is seeking a Pre-Authorization Nurse to review prior authorization requests and determine appropriate care and setting. The role involves clinical judgment to complete medical necessity reviews and refer complex cases to stakeholders.

Responsibilities include educating providers on utilization processes, data entry in management systems, and making independent decisions within established guidelines. Remote work is available with potential travel for meetings.

Qualifications

• Active RN license in VA or compact state (eNLC) with no disciplinary action.
• Minimum 2 years varied clinical nursing in acute, skilled, or rehab settings.
• Experience in utilization management, case management, discharge planning or home health/rehab.
• Proficient in Microsoft Office and remote IT troubleshooting; able to navigate multiple systems.

Responsibilities

• Educates providers on utilization and medical management processes.
• Enters and maintains clinical information in medical management systems; understands department and organizational strategy.
• Makes independent decisions within guidelines and procedures, with minimal direction.

Skills

RN licensure

Clinical nursing 2+ years

Utilization/case management

IT proficiency in remote work

Independent work ability

Tools

MCG guidelines

Interqual guidelines

Job description

Humana, Inc. is seeking a Pre-Authorization Nurse to review prior authorization requests and determine appropriate care and setting. The role involves clinical judgment to complete medical necessity reviews and refer complex cases to stakeholders.

Responsibilities include educating providers on utilization processes, data entry in management systems, and making independent decisions within established guidelines. Remote work is available with potential travel for meetings.